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Book 



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COFntlGHT DEPOSIE 




Types of normal breast- and bottle- fed infants. 
Baby Y., 14 months. Bottle-fed from birth. 2. B. J. S., 11 months. 
Bottle-fed after 4th month. 3. B. S., 6 months. Breast-fed. 



I 



A PRACTICAL TREATISE 

ON 

Infant Feeding 

AND 

ALLIED TOPICS 

FOR PHYSICIANS AND STUDENTS 



BY 

Harry Lowenburg, A.M., M.D. 

Assistant Professor of Pediatrics, Medico-Chirurgical College of Philadelphi 

Pediatrist to the Mt. Sinai Hospital; Pediatrist to the Jewish Hospital; 

Pediatrist to the Jewish Maternity Hospital; Consulting Pediatrist 

to the Hebrew Orphans' Home; Assistant Pediatrist to the 

Medico-Chirurgical Hospital and to the Philadelphia 

General Hospital; Formerly Instructor of 

Pediatrics, Jefferson Medical College. 



Illustrated with 64 Text Engravings and 30 Original Full= 
page Plates, 11 of which are in Colors. 



PHILADELPHIA 
F. A. DAVIS COMPANY, Publishers 

English Depot 
Stanley Phillips, London 

1916 






COPYRIGHT. 1916 

BY 

F. A. DAVIS COMPANY 
Copyright, Great Britain. All Rights Reserved, 



Philadelphia, Pa., U. S. A. 

Press of F. A. Davis Company 

1914-16 Cherry Street 




JI.A418718 



DEDICATION 



IN REVERENT AND AFFECTIONATE MEMORY 
OF MY MOTHER 

HENRIETTA LOWENBURG 



PREFACE. 



The author's purpose in publishing a work upon ''Infant 
Feeding and Alhed Topics" is to meet the many requests 
received from his students and from' his medical colleagues 
who have honored him with: their confidence. The con- 
tents will be found to be largely clinical and practical, and 
to emlx)dy the author's personal experience with the prob- 
lems presented. Theorizing and the presentation of a 
medley of views of different authorities have been studi- 
ously avoided. Credit has not always been given for views 
expressed which are not original, although the attempt has 
been made to do so where the fact stated is eminently new 
and, as yet, has not become a part of commoii medical 
knowledge. Quotations and references have been avoided 
as much as possible, as they are time-consuming and gen- 
erally annoying, distracting the mind of the reader from 
the text. In not a few instances the author has indulged 
in the repetition of certain facts and statements. This has 
been done largely for the sake of emphasis and tO' insure 
the individual completeness of the presentation of the par- 
ticular topic under discussion, and also to avoid references 
and cross-references. 

A serious attempt has been made toi emphasize the im- 
portance of breast feeding and the digestive problems which 
present themselves in this class of patients. 

The influence of the Gennan school of pediatrics has 
been presented in a conservative way, and simply includes 

(v) 



vi PREFACE. 

the author's personal experience with the ideas promiul- 
gated by this brilhant coterie of workers. 

Adherence tO' the percentage idea, in its broader sense, 
has been maintained, as furnishing a valuable method of 
thinking, and not as a ''conditio, sine qua non/' the idea 
being that individualization is the basic principle of suc- 
cessful infant feeding. The advantages and disadvantages 
of the caloric system have been discussed. 

As a means of adapting milk to the individual require- 
ments the top-milk methods and the mlilk-and-cream 
mixture methods have been abandoned as being to^o cumber- 
some, and often incomprehensible toi both the physician and 
to the caretaker. The dilution of whole or of skimmed milk 
is advocated as simple and efficient. Where their use has 
given goad results the author recommends a few pro^ 
prietaries, not as substitutes for, but as adjuvants to cows' 
milk. 

The author's thanks are due, and are hereby gratefully 
acknowledged, to Prof. John B. Deaver, who. has written 
the article upon ^'Surgical Treatment of Infantile Pyloric 
Obstruction." 

To his sister. Miss Sara Lowenburg, the author wishes 
to express his appreciation for her assistance while the 
work was passing through the press. To Robert A. 
Schless, senior student at Jefferson Medical College, and 
to Malvin H. Reinheimer, Esq., for their unselfish and 
enthusiastic assistance in reading proof, and preparing the 
index, the author is likewise gratefully indebted. The 
majority of the Rontgenograms were made by Dr. Geo. 
Ro'senbaum, of Mt. Sinai Hospital, Philadelphia. 

PIarry Lowenburg. 

1927 N. Broad St., 
Philadelphia, Pa. 



CONTENTS, 



CHAPTER I. 

PAGE 

Breast Feeding 1 



CHAPTER n. 
Artificial Feeding 49 

CHAPTER HI. 
Artificial Feeding (continued) 118 

CHAPTER IV. 
Infantile Atrophy 150 

CHAPTER V. 
Rickets 185 

CHAPTER VI. 
Scurvy 222 

CHAPTER VII. 
Vomiting 232 

CHAPTER VIII. 
Constipation 247 

CHAPTER IX. 

Diarrhea 260 

(vii) 



viii CONTENTS. 

CHAPTER X. 

PAGE 

Spasmophilia 276 

CHAPTER XL 
Exudative Diathesis 297 

CHAPTER Xn. 
Pyloric Obstruction 313 

CHAPTER XHI. 
Special Topics 350 

Index 375 



/... 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1 The mammary gland (Gray.) 3 

2 Artificial nipple or nipple-shield 7 

3 Breast-pump. (Physician's Supply Co., of Phila.) 9 

4 Massaging breast 11 

5 Abscesses not interfering with breast feeding 12 

6 Microphotograph of colostrum 13 

7 Microphotograph of human and of cows' milk 15 

8 Stripping of breast for sample 18 

9 Lactometer. (Physician's Supply Co., of Phila.) 19 

10 Creamometer for estimating] percentage of fat. (Holt) 22 

11 Babcock's centrifuge tube for estimating fat. (Arthur H. 

Thomas Co. ) 22 

12 Babcock's pipette for estimating; fat 23 

13 Eschbach's albuminometer used in protein test. (Arthur H, 

Thomas Co.) 23 

14 Types of good nursing breasts 31 

15 How to hold an infant while at the breast 39 

16 Proper can used in milking cows. (Dairyman's Supply Co., 

Philadelphia, Pa.) 64 

17 Freeman's pasteurizer 92 

18 Apparatus used in mixing formula 95 

19 Nursing bottle 96 

20 A good type of nipple 96 

21 Bottle-brush (Physician's Supply Co., of Phila.) 97 

22 Showing correct rapidity of flow of formula through nipple . . 98 

23 Nursery refrigerator. (Courtesy of Gimbel Bros., Phila.) 99 

24 Home buttermilk churner. (Gimbel Bros., Phila, Pa.) 122 

25 Flour ball 134 

26, 27 Essential marasmus 156, 157 

28 Marasmus 158 

29 Frog appearance in essential marasmus 159 

30 Marasmus complicated by edema 161 

31 Atrophy or marasmus due to chronic cerebrospinal meningitis . 167 

32 Square outline of head in rickets 193 

33 Rachitic kyphosis 197 

34 Rickets 198 

35 Rachitic rosary 199 

(ix) 



X LIST OF ILLUSTRATIONS. 

FIG. PAGE 

36 Rachitic scoliosis 201 

Zl Tubercular kyphosis 203 

38 Pot belly and bow-legs 204 

39 Rickets. Anterior bowing of tibia and pot belly 205 

40 Rickets. Pot belly and protruding umbilicus 207 

41 Double congenital dislocation of hip 212 

42 Scurvy 227 

43 Same child after recovery from scurvy 229 

44 Constipation due to dilated colon. (Hirschsprung's disease.) . . 253 

45 Massage balls. (Physician's Supply Co., of Phila.) 258 

46 Percussion hammer 283 

47 Lingua geographica 306 

48 Showing pyloric obstruction 313 

49 Weight curve in a case of complete or surgical pyloric ob- 

struction 317 

50 Effect of posterior gastroenterostomy on weight curve 318 

51 Visible gastric peristalsis 319 

52, 53 Weight charts of two cases of incomplete non-surgical 

pyloric obstruction 326 

54 Weighing the baby 328 

55 From combined weight of baby and towel subtract the weight 

of towel to obtain result 329 

56 Apparatus for stomach washing, etc 351 

57, 58 Stomach washing 354, 355 

59, 60 Colonic irrigation with the catheter 357, 358 

61 Giving a colonic irrigation or a high enema without inserting 

the catheter 359 

62 Nasal feeding 362 

63 Hypodermoclysis 371 

64 Necrosis and ulceration from the subcutaneous injection of car- 

bonate of soda and sodium chlorid solution 372 



LIST OF PLATES. 



PLATE FACING PAGE 

Types of normal breast- and bottle- fed infants. .Frontispiece ^ 

I. Meconium (colored) 16 »/ 

II. Normal breast stool (colored) 28 

III. Normal stool of artificially fed baby (colored) 32 "^ 

IV. Stool of indigestion in the breast-fed (colored) 36 - 

V. Stool of dyspepsia ^(colored) 40 - 

VI. Constipated, greasy stool of artificially fed infant, due 

to administration of too much fat (colored) 64-^ 

VII. Hard, constipated, calcium-soap stool due to adminis- 
tration of too much fat (colored) 80 ' 

VIII. Hard, dry, whitish, constipated, crumbly stool, consist- 
ing of undigested protein, occurring in a bottle-fed 

baby (colored) 104 •" 

IX. Stool of a. case of diarrhea discolored by bismuth 

(colored) 128 

X. Same case as Plate IX. Diarrhea more advanced 

(colored) 144 - 

XI. Tubercular kyphosis 200 

XII. The appearance of the gums in a case of infantile scurvy 

(colored) 224^- 

XIII. Showing stomach-tube i)i situ in a case of intense gas- 

tric dilation 316 

XIV. Practically complete obstruction 320 

XV. Same case as Plate XIV. One hour after the adminis- 
tration of the bismuth 320 

XVI. Same case as Plate XIV. Three hours later. No bis- 
muth has left the stomach 320 - 

XVII. Same case as Plate XIV. Six hours later 320 - 

XVIII. Same case as Plate XIV. The next day, about nineteen 

hours later 320 

XIX. Comet-like appearance of the bismuth shadow at the 

pylorus in cases of complete obstruction 320 - 

XX. Non-surgical incomplete pyloric obstruction 336"" 

(xi) 



xu 



LIST OF PLATES. 



PLATE FACING PAGE 

XXL Same case as Plate XX. Two hours later 336 

XXIL Same case as Plate XX. Bismuth still in stomach, four 

hours after administration 336 

XXIIL Same case as Plate XX. Much bismuth still in the 
stomach, but also seen in descending colon and 

sigmoid 336 

XXIV. Same case as Plate XX. Eighteen hours later 336 

XXV. Case of incomplete but surgical pyloric obstruction 336 

XXVI. Same case as Plate XXV. Bismuth in stomach, two 

hours later 336 

XXVII. Same case as Plate XXV. Four hours later 336 

XXVIIL Same case as Plate XXV. Eight hours later 336 

XXIX. Same case as Plate XXV. Sixteen hours later 336 



CHAPTER I. 
BREAST FEEDING. 



MATERNAL AND MEDICAL RESPONSIBILITY. 

Physicians have long recognized that the best food for 
an infant is human milk. In spite of this, thousands of 
children continue to be placed upon artificial feeding, some 
to thrive, some to live and to suffer from nutritional dis- 
eases, and some to die. The responsibility for the failure 
to conserve the maternal milk-supply, while dual, rests with 
greater weight upon the physician, who, while realizing the 
value of natural and the dangers and uncertainties of arti- 
ficial feeding, has failed to become fired with that enthu- 
siasm which, the subject demands. Consequently miany 
mothers are lacking in enthusiasm. 

It must be stated, first, that the majority of women, 
providing they are disease-free, can nurse their young. 
The physician should, therefore, from the day that his pa- 
tient cotmes under his charge for her expected confinement, 
point out to her at every opportunity the advantages of 
maternal nursing and the dangers of bottle feeding. It is 
a grave error, tooi often committed, to discontinue the breast 
at the first sign of indigestion in the newborn, — an occur- 
rence so common that it may almost be regarded as normal. 
A mother, on the other hand, will frequently believe that 
her baby is not getting sufficient nourishment or that her 
milk is too weak o^r toO' rich, and that altogether she is unfit, 
both from her own and the standpoint of her infant's health, 

1 (1) 



2 BREAST FEEDING. 

to suckle her babe. The psychic element, represented 
by fear and uncertainty in the mothers mind, is a very potent 
cause for the discontinuance of maternal feeding and is ex- 
ceedingly difficult and sometimes impossible to oivercome. 
In fact, fear and anxiety may cause a temporary suspension 
of the lacteal flow, just as of the other secretions, — saliva,, 
for instance. The physician here again fails in his func- 
tion if he thoughtlessly coincides with the mother's ideas 
without investigation. True it is that there are contraindi- 
cations to maternal feeding, but these will really be found 
to be few. In our zeal to secure some substitute for or 
imitation of human milk, we have been carried away from 
the truism that nothing is quite so good as the real article, 
and that, if we would but have it, there is plenty oi it at 
hand ; and that the study of its conser^^atioin is perhaps the 
most urgent duty of the pediatrist and of the practitioner. 

The best guide as to a particular woman's ability to 
nurse is the physical condition of her babe. If its weekly 
gain equals from 5 to 7 ounces or even a little less, then 
nothing else need be considered. In spite of this, on the 
plea that the milk is insufficient in quantity and quality, 
although the simple process of weighing the infant before 
and immediately after nursing for a few times was not 
practised; or that the infant failed tO' gain weight (even 
in the absence of a milk analysis) ; or that it suffered from 
digestive disturbances, physicians are daily sacrificing the 
human milk-supply. Granted that these conditions are 
realities, one may pertinently ask ''Doi they constitute a suffi- 
cient reason to stop breast feeding?"^ Certainly not! As 
will be pointed out later, there are methods of conserva- 
tion and of correction whereby the milk can be increased 
in quantity or whereby any or all of the various elements 



MAMMARY GLAND. 



may be augmented or diminislied. These it is the physi- 
cian's duty to know and toi practise. The mother, on her 
part, should look to her medical advisor alone, and not de- 
pend upon the gratuitous advice of well-meaning but ])oorly 
informed friends. 

Breast feeding may be done either by the motJicr (ma- 
ternal nursing) or by a wct-nursc (wet-nursing). The 




Fig. I. — The mammary gland. (Gray.) 

former is by far the more satisfactory. The latter is useful 
in emergency. As the milk is secreted by the mammary 
glands, the construction and function of these organs should 
be understood. 

MAMMARY GLAND. 

The mammae, or breasts, secrete the milk and are two, 
large, hemispherical eminences situated on the lateral aspect 
of the chest, between the third and the sixth or seventh ribs, 
and between the sternum and the axilla (Fig. i). They 



4 BREAST FEEDING. 

vary in size in different woinen and in the same woman, 
depending upon the physiologic activity of the uterus. The 
left breast is a trifle larger than the right. Before puberty 
they are insignificant, but increase in size as the generative 
organs develop. During preg'nancy they enlarge and re- 
main so during active lactation. The shape of the oirgan, 
as a rule, changes from a circular convex outline tO' a large, 
pendent mass. The nipple is a small, conical eminence 
placed just below the centre oif the gland. The skin cover- 
ing the nipple and surrounding its base contains pigment, 
the amount and character of which depend upon the type 
O'f woman (blonde or brunette) and upon the activity of 
the gland. This pigment, called the areola, in the virgin 
is of a delicate rose tint. As pregnancy advances it beco'mes 
darker and spreads over a larger area,, extending from the 
base oi the nipple over the surface of the gland (secondary 
areola). 

In brunettes of pronounced type this secondary pig- 
mentation may be black. The skin covering the surface 
of the gland, besides being pigmented, also becomes striated 
much after the fashion of the skin of the abdomen. The 
nipple contains involuntary muscle-fibre, which, under sex- 
ual excitement or the irritation produced by the infant's lips, 
contracts, causing the nipple tO' become erect. The nipple is 
perforated at its tip by the numerous orifices of the galacto- 
phoroiis ducts. Around the base of the nipple are found 
several sebaceous glands which serve to keep the skin in a 
pliable condition (glands of Montgomery). Numerous 
nerves find their endings in the cutaneous papillae of the 
nipple. 

Histologically the mammae are tubo'-racemose glands 
(Piersol), containing fifteen to twenty lobes, which are 



MAMMARY GLAND. 5 

/ 
separated and supported by masses of adipose tissue and by" 

fibrous septa, which divide the lobes into lol)ules and these 

again into acini. These acini are lined by a low columnar 

epithelium, which varies in character, depending upon the 

functional activity of the gland. These cells, resting upon a 

membrana propria, rapidly multiply and oil-droplets appear 

within them. These gradually increase in amount and 

coalesce until they occupy almost the entire content of the 

cell, crowding the nucleus and the protoplasm, to one side. 

As the amount of oil increases the cells become distended 

and finally rupture, the oil being discharged into the lumen 

of the acinus, where, becoming mixed with an albuminous 

secretion and epithelial debris, constitutes the secretion of 

the gland, or milk. The cells near the centre of the acinus 

undergo fatty degeneration and are discharged for a few 

days following the establishment of lactation. These cells 

constitute the large colostrum corpuscles (Fig. 6) which 

persist for a week or ten days, and the first secretion is 

known as colostrum. The nuilk is carried off by means of 

ducts which extend from each acinus. These are called 

lactiferous ducts, and they unite with those from other 

acinii and foirm the lobular duct which joins with those 

from other lobules, and finally this union terminates into 

the lobar duct or galactophoroiis duct, which passes as a 

single tube, ununited, from each lobe and opens by a separate 

outlet intoi the apex of the nipple. Just before it reaches 

the apex oif the nipple, eacli duct dilates into^ a pouch or 

ampulla. These ampullae act as reservoirs for the milk. 

The ducts are lined with low columnar epithelium' which 

rests upon a membrana propria, and each duct possesses a 

fibrous coat which contains elastic tissue and some unstriped 

muscle-fibre. As the ducts approach the surface of the 



6 BREAST FEEDING. 

nipple the lining epithelium becomes stratified and con- 
tinuous with that of the epidermis. 

The internal mammary, the thoracic branches of the 
axillary, and the intercostal arteries supply these organs 
with blood, and their branches penetrate the entire gland, 
even surrounding the acini in a capillary network. The 
venous blood from the interior of the gland is carried by 
venules to the circulus venosus surrounding the nipple. 
Thence large branches carry the blood to the circumference, 
terminating in the axillary and the internal mammary veins. 
The lymphatics empty for the most part into the anterior 
axillary glands and some few into the anterior mediastinal 
glands. During lactation the vascular supply tO' the mam- 
mae is increased and the veins become decidedly prominent. 
The anterior and lateral nerves of the thorax supply the 
mammas with innervation. 

HYGIENE OF THE BREAST AND NIPPLES. 

After each nursing, the nipples are gently cleansed with 
a piece of absorbent cotton moistened with boric acid solu- 
tion and gently dried. The infant's mouth is cleansed in a 
similar manner with a mild antiseptic alkaline solution. Be- 
fore nursing the nipples should also» be cleansed. No' milk 
should be permitted to dry or to sour upon the nipple, as 
digestive disturbances are likely tO' follow as well as mam- 
mary infection. Excoriations and fissures of the nipples 
may cause excruciating pain. They can often be prevented 
by bathing the parts during the entire period of gestatiion 
with a solution of alum in alcohol, thereby rendering the 
epithelium tough. When present, temporary suspension 
of breast feeding may become necessary for a few days, or 
the artificial nipple may be employed (Fig. 2). Experience 



HYGIENE OF BREAST AND NIPPLES. 7 

with this instrument is not always satisfactory. It may, 
annoy the mother, and the infant may not take to it kindly. 
A better method is to withdraw the milk by manual manipu- 
lation, and to feed it to the baby through a bottle or by 
means of a spoon. The application of some sedative dusting 
powder, as equal parts of bismuth and boric acid, is often 




Fig. 2. — Artificial nipple or nipple-shield. 

serviceable. Before nursing, the powder should be care- 
fully wiped away. Indolent fissures are stimulated to heal- 
ing by touching them with a stick of silver nitrate. Com- 
presses wet with a lo per cent, solution of argyrol or 
ichthyol are also useful. Better than all these is a paste 
made from equal parts of bismuth subnitrate and castor oil. 
An ointment of calendula, prepared by homeopathic phar- 
macies, applied to the sore places, has often yielded good 
results. 



8 BREAST FEEDING. 

ECZEMA OF NIPPLES DURING PUERPERIUM. 

Eczema of the nipples and of the neighboring integu- 
ment is a troublesome complication of the puerperium and 
may seriously interfere with nursing. Water should be 
kept away from the parts. The condition usually yields to 
the combination of castor oil and bismuth. If there be 
present indurated fissures, salicylic acid gr. x and lanolin 
Ej will usually cause them to heal. 

DEPRESSED NIPPLES. 

The nipples may be depressed below the surface of the 
gland, or they may be inverted or even absent. The de- 
pression may disappear under the stimulus of sexual excite- 
ment or of the infant's lips. Depressed or inverted nipples 
may be a serious handicap' to maternal feeding. For this 
reason throughout the puerperium, the mother should be 
taught tO' daily draw the nipple out with her fingers or with 
the breast pump. It is surprising, on the other hand, to note, 
in some cases wherein the galactophorous ducts open 
directly upon the surface of the glands, with practically no 
nipple, with what ease the infant seizes the breast and 
maternal feeding is successfully accomplished. 

CAKING AND ABSCESS OF THE BREAST. 

If the milk enters the breast too rapidly, or if it fails 
tO' be withdrawn, by proper nursing, it collects in the lac- 
tiferous tubules and in the acini of the mammary gland, 
causing them to distend. This is known as caking. The 
breast becomes exceedingly painful and, especially in the 
dependent portions, are felt the hard and tender lobes of 
the gland. Caking is best prevented by regular and steady 
nursing. If in spite of this an excess of milk is secreted. 



CAKING AND ABSCESS OF BREAST. 9 

the breast pump (Fig*. 3) may be used to remove the excess, 
and the breasts are gently massaged with warm oil several 
times a day, care being exercised to make the stroke in the 
direction oi the ducts, from the base toward the nipple 
(Fig. 4, A and B). 

Abscess of the breast is a preventable as well as a lament- 
able accident. It results directly from mammary infection. 
Infection may be carried into the lobules of the glands 
through cracks in the nipple, through eczematous excoria- 




Fig. 3. — Breast-pump. (Physician's Supply Co., of Phila.) 

tions, by the mouth of the infant, and by the decomposition 
of milk left to dry upon an imperfect nipple. The nurse 
or physician may carry infection to the breast by undue 
manipulation. 

Symptoms.— Abscess may appear at any time during the 
nursing period. It is more common during the earlier weeks. 
There may be few if any constitutional symptoms. On the 
other hand, the general reaction may be severe, the patient 
complaining of chilly sensations or suffering a real rigor. 
The temperature rises to 101° F. or to 103° F. (rarely 
higher), and the pulse is proportionately increased. Ano- 
rexia and nausea, as well as headache and neuromuscular 
pains occur. The tongue is coated and the bowels become 
constipated. 



10 BREAST FEEDING. 

Locally there appears a small or a large, circumscribed 
spot oif induration which is tender and which varies in size 
from a marble to a walnut. More than one such area may 
thus appear. The overlying skin becomes bright red. It is 
not at first adherent, but later becomes so. The color dark- 
ens, the area softens, often increasing to an enormous size, 
spreading not only superficially, but deeper into the substance 
of the gland. The skin is hot, the pain intense, and fluctua- 
tion is made out with ease or difficulty, depending upon the 
depth of the infection. Spontaneous rupture may occur with 
a disappearance of general symptoms, to be followed by 
slow healing and perhaps one or more remaining sinuses, 
which may or may not intercommunicate. These sinuses 
may persist for months. 

Treatment. — Aside from incision and drainage, as soon 
as fluctuation manifests itself, the effect of mammary abscess 
upon the future ability of the mother to nurse her babe must 
be seriously considered. At first thought it would appear 
that a mammary gland, once infected, is lost to the infant 
forever. AA^hile true in most cases, one must discriminate 
and determine each case individually. The size and the posi- 
tion of the abscess, and^ also' zuhether or not pus is being 
secreted at the nipple, largely inftiience the decision. This 
may be recognized by the naked eye; or bacteria, pus cells, 
and perhaps blood may be discovered by the microscope. If 
the other breast be healthy it may yield sufficient milk. At 
least partial breast feeding should be employed. If on the 
other hand, as in a case in point, in which the abscess was 
as large as a marble and in which no- pus appeared at the 
nipple by reason of the fact that the galactophoroas duct 
leading to it, between it and the abscess, was obliterated by 
an adhesive inflammation, the infant will not receive any 



COLOSTRUM. 



13 



is slow search sliould be made in the mother for tuber- 
culosis or for some depressing diathesis. Change of air, 
good food, Basham's mixture or iron citrate, with other 
tonics, hypodermically, should be used. Autogenous or 
stock vaccines should also be employed as adjuvants. 




Fig. 6. — Microphotograph of colostrum. A, the large nucleated 
and granular colostrum corpuscles ; B, oil globules. 



COLOSTRUM. 

About the third day of the puerperium milk makes its 
appearance in the mother's breast. This first lacteal secre- 
tion is not really milk, but consists largely of water and is 
comparatively rich in protein. It is known as colostrum 
and microscopically contains large, granular, corpuscular 
bodies, about five times the size of milk-corpuscles. They 
are known as colostrimn corpuscles, and probably represent 
desquamated epithelial cells which line the acini of the mam- 



14 BREAST FEEDING. 

mary gland (Fig. 6). Colostrum also contains globules 
of oil. Its composition is variable, as indicated by the table 
of Harrington, quoted by Rotch : — 

I II III IV V 

Fat 1.40 0.68 2.40 5.73 4.40 

Milk-sugar and pro- 
teins 9.44 11.53 II. 15 10.69 11.27 

Ash 0.17 0.31 0.25 0.16 0.21 

Total solids ii.oi 12.52 13.80 16.58 15.88 

Water 88.99 87.48 86.20 83.42 84.12 

100.00 100.00 100.00 100.00 100.00 

As indicated, the quantity of fat is comparatively low; 
while the percentages of milk-sugar and of proteins are high 
and uniform. The function of colostrum is but little under- 
stood. It probably does not contribute toi the nutrition of 
the infant. In fact, the reverse is true, for during the first 
week of life the infant's weight is diminished. Its effect 
is probably that of a laxative, ridding the bowel of meco- 
nium. ColoiStrum disappears in about one week to ten days, 
and is replaced by true milk. 

CHEMISTRY AND PHYSICS OF HUMAN MILK. 

Human milk, as well as cows' milk, is an emulsion. It 
is an opaque fluid, bluish white in appearance, and has a 
sweet, palatable taste. Its reaction is alkaline or amphoteric 
when freshly drawn. The specific gramty varies between 
1029 and 1030. 

Under the microscope the milk is seen tO' consist of a 
Uiiid portion and of corpuscular elements (Fig. 7, A). 
These corpuscles are minute, evenly divided, fat globules, 
which are held in suspension. When milk is acted upon 
by rennin and slightly warmed it coagulates. The coagu- 



CHEMISTRY AND PHYSICS OF HUMAN MILK. 



15 













// 







9i 



o 







^fJ 



w^/^''^ 



Fig. 7.— Microphotograph of human and of cows' milk. I. Normal human milk 
showing uniformity in size of fat globules (A). The apparent smallness in 
the size of those in the centre is due to the focusing. Note the absence of 
epithelial cells and leucocytes. The presence of the latter would indicate in- 
flammation of the breast, probably beginning abscess. II. Cows' milk showing 
the comparative irregularity in the size (larger) and shape of the fat globules 
(A) with reference to human milk. Also note the absence of epithelial cells 
and leucocytes, showing the teat to be free of inflammation. 



16 BREAST FEEDING. 

lum consists of calcium paracasein (casein) or principal 
protein constituent of the milk, in the meshes of which 
are contained the fat globules. In the normal state this 
protein exists as calcium casein (caseinogen). From- the 
coagulum exudes a clear, watery fluid called whey. Whey 
contains the soluble and non-coagulahle proteins,^ lact- 
albumin and lad o globulin. The former is coagulated by 
heat; the latter is not. Whey also' contains the salts and 
sugar of milk in solution and a small amount of fat. Two- 
thirds of the protein in human milk are lactalbumin and 
lactofglobulin. In cows' milk but one-fourth of the total 
protein is composed of these constituents. 

The chemical composition of human milk varies. It 
varies in different women and in the same woman at differ- 
ent periods of the same nursing and at different times 
throughoiut the entire period of lactation. The composition 
varies as to the number of daily feedings and the length 
of each feeding. It also depends upon the character and 
quantity of the mother's food, her environment, tempera- 
ment, the care she has received during her accouchement, 
and the amiount of physical exercise. The nearer to nature 
a woman lives, the more normal will he her milk-supply. 

The percentage of fat is the most variable constituent. 
It is the lightest element in milk, and, if the milk be per- 
mitted to stand, it rises tO' the surface and constitutes cream. 
Cream does not consist entirely of fat, but contains the other 
chemical substances found in milk. According to Holt, the 
ratio of the fat to the cream is as 3 is to 5. The fats of 
milk are composed of stearin, olein, and pahnitin, and are 
in fixed combinations, the amount of volatile fatty acids be- 
ing decidedly less than in cows' milk. 

1 Non-coagulable with reference to renin. 



PLATE I 




Meconium. 



ANALYSIS OF IIUMAX MILK. 



19 



instruments is tedious and unsatisfactory. The pump and 
the bottle which is to receive the sam])le sliould be sterihzed. 
The color of human milk is bluisli wliitc in appearance. 
It has no characteristic odor. 

A li 




Fig. 9. — Lactometer. (Physician's Supply Co., of Phila.) 

Reaction. — This is tested by litmus-paper. 

Specific Gravity. — This is determined by an ordinary 
urinometer or a special lactometer (Fig. 9). The milk is 
put into a small cylinder, A, and the instrument, B, is lowered 
into the former with a slight spin to avoid sticking to the 



20 BREAST FEEDING. 

sides. When it has come to rest the graduation on the 
neck is read. The temperature of the milk should be 60° F. 
The specific gravity furnishes crude but valuable compara- 
tive data for clinical purposes. Thus the fat, being the 
lightest constituent of milk, when in excess would cause the 
specific gravity to be low, provided the other solid con- 
stituents were normal. Conversely, under the same condi- 
tions a high specific gravity would indicate that the per- 
centage of fat must be low. If the percentage of fat is 
normal and the specific gravity is high, this would indicate 
that the remaining solids were high. The reverse means 
that there is a deficiency of the other solids. Therefore, too, 
if the specific gravity be normal and the fats are high, the 
other solids are high. If the fat be low and the specific 
gravity is normal, then the other solids are low. 

Table Showing Relation of Known Percentage of Fat and Specific 
Gravity to Remaining Solids. 

High fat and normal specific gravity = High remaining solids. 

Low fat and normal specific gravity = Low remaining solids. 

High fat and high specific gravity = High remaining solids. 

Low fat and high specific gravity = Low remaining solids. 

High fat and low specific gravity = Low remaining solids. 

Low fat and low specific gravity = Low remaining solids. 

Daily Quantity Secreted. — This is with difficulty deter- 
mined, and can only be estimated by weighing a baby which 
is gaining steadily, before and after each feeding through- 
out the entire twenty-four hours. From several such daily 
assays an average can be struck. The following table from 
Holt^ gives approximate quantities which may serve as a 
guide : — 



1 Holt, ''Diseases of Infancy and Childhood," page 130, 6th edition. 



ANALYSIS OF HUMAN MILK. 21 

Ounces. Grams. 

At the end of the first week lo to i6 300 to 500 

During second week 13 to 18 400 to 550 

During third week 14 to 24 430 to 720 

During fourth week 16 to 26 500 to 800 

From the fifth to thirteenth week 20 to 34 600 to 1030 

From the fourth to sixth month 24 to 38 720 to 11 50 

From the sixth to the ninth month 30 to 40 900 to 1220 

Determination of Fat. — The simplest method is hy the 
cream gauge devised hy Holt (Fig. 10). The only objec- 
tion to its use is that it requires twenty-four hours. The 
instrument is graduated into too parts and is fitted with a 
ground-glass stopper. It is filled to the zero mark with 
milk, and is allowed to stand for twenty-four hours at room 
temperature. The volume occupied by the cream is then 
read off. The percentage of fat to the cream is as 3 is to 5. 
This mathematical formula is arbitrary. The results, how- 
ever, are useful for practical purposes, as it is possible to 
learn whether an increase or a diminution has taken place, 
provided a reco«rd of each examination is kept. 

A simple and accurate method is the test of Babcock. 
Place in the special percentage centrifuge tube (Fig. 11), 
by means of a graduated pipette (Fig. 12), 17.6 c.c. of milk. 
Clean the pipette and add 17.6 c.c. of strong sulphuric acid, 
holding the percentage tube in an inclined position. The 
acid sinks to the bottom. Mix the two liquids by means of 
a rotary motion. The mixture becomes dark brown or 
black, and hot. The sulphuric acid dissolves the calcium 
paracasein, and the heat generated is sufficient tO' liquefy 
the fat. Place the percentage tube and contents in a centri- 
fuge and rotate 1200 times a minute for six minutes. Now, 
by means of the pipette, run enough hot water into the per- 
centage tube to bring the level of the fluid up to the highest 
graduation. Rotate again in the centrifuge for two minutes. 



22 



BREAST FEEDING. 



Note on the graduated neck the volume occupied by 
the fat. Each unit division indicates one unit per cent. 







~(\ 




Fig. II. — Babcock's centrifuge 
Fig. 10. — Creainometer for estimating tube for estimating fat. (Ar- 
percentage of fat. (Holt.) thur H. Thomas Co.) 

Readings can be made to one-fourth of i per cent. (0.25 
per cent. ) . 

Determination of Proteins. — If the specific gravity and 
the percentages of fat, sugar, and saks be known, the per- 



ANALYSIS OF HUMAN MILK. 



23 



centage of proteins may be calculated from the percentage 
of total solids. The total solids equal the sum of one- 



\ 



'% 




Fig. 12. — Babcock's pipette 
for estimating fat. 



Fig. 13. — Eschbach's albuminometer 
used in protein test. (Arthur H. 
Thomas Co.) 



fourth of the last tzco figures of the specific gravity, plus 
six-Hfths of the percentage of fat, plus 0.14. This may be 
expressed as follows: — 



24 BREAST FEEDING. 

Last two figures of S. Gr. (% of fat X 6) 

Total solids = + + -14 

4 5 

This result minus the sum of the percentages of fat, 
sugar, and salts equals the percentage of proteins. 

Example. — The specific gravity is 1030. The percentage 
of fat, sugar, and salts is, respectively, 4, 7, and 0.2. 

30 (4 X 6) 

Total solids ^ — + + .14 = 12.44% 

4 5 

Percentage of proteins = 12.44% — (4% + 7% + 0.2%) 
= 12.44% — 11.2% = 1.24%. 

A more accurate method is that described by Kjeldahl, 
but is too complicated for practical purposes. 

The following method provides accurate com^parative 
data. The solution required consists of 

Phosphotungstic acid, 25 Gm. 
Distilled water, 125 c.c. 

After thorough solution is obtained, add 

Hydrochloric acid, concentrated, 25 c.c. 
Distilled water, 100 c.c. 

The solution if kept in a blue bottle will remain stable for 
a long while. Human milk is diluted i to 10, or, if the 
protein is thought to be very low, i to 5. The diluted milk 
is poured into an Esbach tube such as is used for the estima- 
tion of albumin in urine (Fig. 13) to the mark U. The 
solution is added to the mark R; the tube corked and slowly 
inverted 12 times. It is allowed to remain upright for 
twenty-four hours, and the percentage of protein is read 
at the level of the precipitate. 

Estimation of Lactose. — The calcium casein is precipi- 
tated by acidulating the milk with acetic acid, and the 



INDICATIONS FOR MILK ANALYSES. 25 

lactalbumin by boiling the acidulated mixture. Filter. 
Wash the precipitate with a measured quantity of distilled 
water, which is added to the filtrate. When cool, place in a 
burette and titrate with Fehling's solution, as when 
examining urine. The reduction factor for lactose differs 
from that of glucose, lo c.c. O'f Fehling's solution being 
equivalent to 0.06 Gm. of lactose, instead of 0.05 Gm. of 
glucose. 

Microscopic Appearance. — Human milk contains great 
numbers of small fat globules of uniform size floating in 
the watery portion oi the milk (Fig. 7, I). Thus, it is 
seen to be a perfect emulsion. No other cellular elements 
aside fronn an occasional epithelial cell or a leucocyte are 
seen. The last two appearing in excess indicate an abnor- 
mality, usually inflammation or abscess. 

INDICATIONS FOR AND INTERPRETATION OF 
MILK ANALYSES. 

For clinical purposes it is proper to inquire ''When do 
conditions arise that demand or which would be benefited 
by a careful analysis of the milk which the infant is re- 
ceiving, and hoiw are these results to be interpreted?" 
Unless there be a distinct indication, the interest attached 
to such an examination is purely academic, and serves no 
practical purpose. On the other hand, if the infant is not 
thriving, or if there be evidences of indigestion and colic, 
or if the mother doubts the good quality of her milk, 
analyses are of use. 'Tf the analysis shows the milk to be 
poor in all its constituents, does this mean that it is an unfit 
food for the particular baby receiving it?" Not necessarily. 
The best guide is the condition of the baby itself, and not 
infrequently is it seen that an infant will gain steadily on 



26 BREAST FEEDING. 

what appears to be a weak milk, while another will not 
thrive on a rich one. If, however, there exists a combina- 
tion of an undernourished babe together Avith a poor milk, 
the indication is clear to improve the quality of the mother's 
milk or to try mixed feeding, or, as a last resort, artificial 
feeding alone. 

The value of a milk analysis, in determining which of 
the food elements of the breast milk are responsible for the 
symptoms of indigestion, is incalculable, and often is the 
means of saving to the infant the maternal milk. The in- 
formation thus obtained frequently permits the physician 
to speedily correct the trouble through treatment of the 
mother. 

Psychic influences exert a tremendous effect upon the 
secretion of breast milk, and if a milk analysis will con- 
vince a doubting, fearful, though willing woman, that her 
milk is of good quality, the time consumed and the expense 
will have been well worth while. 

ADVANTAGES OF BREAST FEEDING. 

In his daily contact with his patients the general practi- 
tioner meets no question with more frequency than that deal- 
ing with the nutrition of the infants under his charge. His 
responsibility has been indicated already with ref erence ■ tO' 
the necessity of attempting the conservation of the human 
milk-supply. The question may very properly be asked, 
''What are the advantages of breast feeding?" They in- 
volve both the mother and the infant, and if the physician 
has the facts ready at hand, many converts to the ranks oi 
those who suckle their young, and thereby serve as a potent 
instrument in lowering infant mortality, will be gained by 
him. 



ADVANTAGES OF BREAST FEEDING. 27 

Gastrointestinal and nutritional diseases are responsible 
for j^^.j per cent, of all the deaths which occur in infants 
during the first year (Holt). Practically all of these are 
artificially fed. This should be sufficient argument to en- 
courage both physician and mother to conserve the milk- 
supply, and should at once take the right from both or 
either to arbitrarily decide whether the infant should re- 
ceive the breast or not. It makes the obligation mandatoi*y. 
Too frequently the breast is sacrificed because, without 
investigation, carelessly and heedlessly the physician or the 
rnother, or the fonner yielding to the wishes of the latter, 
decides that the milk is unfit food for the baby. A woman 
may declare for a whim that she does not want to nurse her 
infant; that it will interfere with her social duties; that 
it is not aesthetic; that Doctor So-and-So knows how to 
feed babies artificially, and that she will put her infant 
under his care; that she has a friend who- reared a baby on a 
popular patented food, and that she will do the same. 
These and many others are the reasons for withdrawing the 
breast. Neither physician nor layman possesses an inherent 
right to destroy a helpless babe's means of sustenance. 
The obligation of marriage and motherhood carries zmth it 
to the healthy zuonian the obligation of maternal nursing 
for nine months at least. 

Digestive disturbances occur with less frequency and 
with less severity in the breast-fed. They are usually of 
no consequence, and seldom are associated with nutritional 
disturbance. Breast milk possesses antirachitic and anti- 
scorbutic properties not found in any other food. In 
human milk there probably exists certain substances which 
confer upon the infant a natural immunity against the acute 
infectious diseases, as these occur with extreme raritv dur- 



28 BREAST FEEDING. 

ing the first year, especially in the breast-fed. On the 
other hand, their incidence in this class of patients is 
marked by less severe symptoms and recovery is the rule. 
In the breast-fed dentition is rarely troublesome. Breast 
babies gain regularly in weight, sleep well, and are happy. 
The so-called dreaded second summer does not exist for 
the naturally fed infant, and danger of milk infection is 
absent. The food is always practically sterile, of the 
proper temperature, and requires no preparation. 

From the mother's standpoint the knowledge of having 
a healthy child should be sufficient compensation for any 
material inconvenience which she fears she might have 
to endure. Some women honestly think they cannot nurse 
their infants or that their food is insufficient, consequently 
they discontinue nursing or use other foods in conjunction 
with it. It is difficult to convince these women as to the 
fallacy in their idea, and they gO' from one physician to 
another until they find one whoi places the baby upon 
"modified" milk. This usually disagrees, and when the 
infant has passed the gamut of all the patent foods and 
summer diarrhea it is returned to the specialist, dyspeptic 
and marantic, to be remodeled. 

If feeding be conducted with system and regularity, the 
nursing mother will not be prevented from attending to her 
other duties. Between nursings she may rest, and gO' out, 
and after three months the baby may be trained tO' sleep 
from 8 P.M. until 6 a.m. The mother should not, on the 
other hand, be permitted to deceive herself with the idea 
that bottle feeding is easier than breast feeding. Aside 
from the uncertainty and dangers associated therewith, the 
former requires considerably more time on account of the 
necessity of preparation. This, taken in connection with 



PLATR TT 



> 








tf 


i' 

k 




A 



Normal breast stool. 



INDICATIONS OF UNSUCCESSFUL FEEDING. 29 

the inconvenience caused by sickness, places artificial feed- 
ing at a decided disadvantage. 

INDICATIONS OF SUCCESSFUL FEEDING. 

A baby thriving on the breast up to the first six months 
should gain from 5 to 7 ounces a week. It may be a little 
less or a little more. After this, while progressive, the 
weekly increase is less. The normal stool of a breast-fed 
infant is yellow, smooth, mushy, and free of particles and 
of mucus (Plate II). It has a pleasant, slightly acid 
odor, and is weakly acid in reaction. The bowels move 
from one to four times a day. Vomiting does not occur. 
The infant may regurgitate a little food just after feeding 
or when unduly handled. Unless viciously trained, it is 
happy, contented, does not cry, sleeps peacefully between 
feedings, and awakens regularly at feeding time. 

INDICATIONS OF UNSUCCESSFUL FEEDING. 

If the infant does not thrive, if its gain in weight is 
small or unsteady, or it does not gain at all; if it vomits, 
has indigestion, is fretful and sleeps poorly, the cause will 
rarely lie in the mother's milk. More commonly there will 
be found some error in training, or the infant has received 
other food in addition, or is suffering from some organic 
disease of the gastrointestinal canal. Very commonly breast 
babies may be constipated, and the mothers are in the habit 
of daily using an injection or a suppository. Not only is 
this unnecessary, but in many instances is directly respon- 
sible for the inauguration and continuance of constipation. 
The mother should be taught to allow the' infant toi go 
thirty-six hours before resorting to laxatives, suppositories, 
or injections. At the end of this time, and usually before, 



30 BREAST FEEDING. 

the baby will have had an evacuation. Before the breast 
is withdrawn as the cause of trouble, every other possible 
etiolo'gic factor must be investigated. 

MOST COMMON CAUSES OF FAILURE OF MILK-SUPPLY 
AND HOW TO PREVENT THEM. 

From the day that she places herself under her physi- 
cian's care the prospective mother must not only be taught 
the importance of breast feeding, but more forcibly still 
must she have impressed upon her her ability to accomplish 
the act. Psychic phenomena, doubt and fear, especially, 
that the milk-supply is insufficient in quality or quantity or 
both, as before stated, are often responsible for the suspen- 
sion of the flow. Such a case recently came to notice in 
which by persistent persuasion it was possible to carry the 
mother along for four months during the summer. Her 
milk-supply was scant. Each week she asked her physician 
for a formula, and each time was refused because her baby 
gained. In the fall, after weaning had been accomplished, 
she complained of an overabundance of milk, and means 
had to be taken to dry it up. Once the element of fear was 
removed, her milk-flow became plentiful. Shock, fright, or 
sudden joy may temporarily, but rarely permanently, impair 
the flow. Insufficient rest, a continuous round of social 
pleasures, excessive indulgence in alcohol, too much 
physical work and tooi little food, together with poverty, 
especially where the mother must go out to assist in earning 
her living, — all, by interfering with the proper metaboilism 
of the maternal organism, inhibit or prevent the mammary 
secretion. 

Any condition that causes a sudden or continuous loss 
of blood or of the other body fluids seriously menaces the 



PLATR TIT 




Normal stool of artificially fed babv, 



METABOLIC AND DIGESTIVE DISTURBANCES. 33 

symptoms are largely objective and may be referred to the 
stomach and bowels. Vomiting in the suckling, as the 
direct result of dyspepsia, depends largely upon excessive 
individual feedings, too frequent feeding, undue handling, 
and upon an excess of fat or sugar in the mother's milk. 
Food comes up unchanged v^hen vomiting occurs immedi- 
ately after feeding, or, if appearing an hour or twO' later, it 
is sharply acid, smells like rancid butter, and is yellowish 
white in appearance. Excessive fat also causes loose 
bowels, which may contain considerable mucus. The move- 
ments average from four to five a day, are usually yellow, 
occasionally green, and contain white masses that resemble 
softly fried white of egg which has been chopped up and 
scattered throughout the yellow mass (Plate IV). These 
white masses are soluble in ether, readily burn, and are 
turned black by osmic acid. These babies usually have some 
colic and may be fretful and irritable. If the stool be placed 
in water, oil-drops float upon the surface. Sudan III, as 
stated elsewhere, has an affinity for fat, staining it a bright 
red. 

If there be a deficiency of fat, the* infant fails to gain, 
becomes constipated, irritable, and if the condition con- 
tinues, rickets is a common sequence. 

Indigestion depending upon an excess of sugar is marked 
by a sonr, watery vomitus which burns the infant and causes 
it to cry. The bowels are loose and watery, highly acid, and 
excoriate the anus and buttocks. Colic is comimon. The 
temperature may reach several degrees above normal. 

A deficiency of sugar causes subnormal temperature, 
loss of weight, irritability, and constipation. 

Protein excess may or may not be associated with vomit- 
ing of curds. Most commonly the bowels are loose and 



34 BREAST FEEDING. 

contain yellowish-white masses which are tough and which 
react to the test for protein (xanthoproteic). The move- 
ments (Plates IV and V) are green or yellow or yellow- 
ish green, and contain some mucus. The constipated dry, 
crumbly movement of protein excess (Plate VIII) is not 
met with in the breast-fed. 

A deficiency of protein means underdevelopment, sta- 
tionary or decreasing weight, late walking, late dentition, 
anemia, asthenia, constipation, and irritability. The con- 
dition may pass on to rickets. 

An excess of mineral matter causes diarrhea; a defi- 
ciency, constipation and scun^y. 

Treatment. — The most important thing tO' remember is 
that when symptoms of indigestion or of metabolic disturb- 
ances occur in the breast-fed, the first thing not to do is to 
take the child from the breast. This is commonly done, and 
from this time on dates the beginning of many cases of 
fatal diarrhea and inanition. Indigestion in the breast-fed 
is not a serious condition, and usually lends itself readily to 
intelligent management. The essential thing is to watch the 
infant's weight from week to week, and its development. 
If it shows a steady gain nO' change should be made. In 
any case, the breast should not be given up without at least 
one month's observation. In the mean time, if the symp- 
toms be severe, an initial purge of castor oil may be given, 
although this is not often necessary unless the symptoms of 
colic be unusually severe. A hunger period, allowing only 
weak tea sweetened with saccharin, gr. j to the quart, an- 
swers best, and an earnest attempt should be made tO' modify 
the mother's milk (Chapter IX). If any of the ingredients 
are in excess, especially the fat or protein, a little plain 
water or barley-water, well diluted, should be given ten 



MODIFICATION OF MATERNAL MILK. 35 

minutes before feeding^ time in order to dilute the milk. 
More troublesome, and no more useful, is the withdrawal 
Q/f the milk from the breast, diluting it and feeding it from 
a bottle. Colic, if troublesome, is usually relieved by the 
castor oil, or by 5 to lo drops of the aromatic fluidextract 
of cascara, or by 5 toi 10 drops of essence of peppermint in 
hot water, or half a dram to a dram of aqua camphorse or 
aqua menthae sodse (soda mint) in conjunction with the 
hunger period. A spice poultice is soothing if applied to 
the belly. The same quieting effect may be secured by a 
warm asafetida enema or lO) to 30 mm. of the milk of 
asafetida by the mouth. After feeding, the following 
powder may be of service : — 

Extract of pancreatin (Fairchild's) gr. j to gr. ij. 

Taka diastase (P. D. & Co.) gr. j to gr. ij. 

Sac. lactis gr. v. 

In cases with subnormal temperatures, external heat and 
massage with plain or with codliver oil are useful. 

The further treatment includes an intelligent modifica- 
tion of the mother's milk based upon a correct diagnosis as 
to which of the ingredients of the milk are at fault. 

MODIFICATION OF MATERNAL MILK. 

It has been showm how maternal milk may disagree 
with an infant owing to an excess or tO' a deficiency in any 
one of its chemical constituents. Such a contingency may, 
at times, be overcome by the use of certain hygienic meas- 
ures which have the power of influencing the composition 
of the milk. 

Excess of Fat. — This is a matter of individual idiosyn- 
crasy. In reaching a conclusion the result of the analysis 
may not be taken alone. One infant may show disturbance 



36 BREAST FEEDING. 

on 2 per cent, fat and another may tolerate 5 tO' 6 per cent. 
Give the mother a morning purge, preferably Epsom salts. 
Increase her liquids, especially water and weak tea. In- 
crease her exercise. Lessen somewhat the amount of all 
food, especially milk, removing the cream from it in some 
cases. Cut down the proteins (beef, peas, and beans) and 
the fat in her diet. 

Deficiency of Fat. — Control diarrhea, lessen exercise, 
and increase the beef and other proteins, and fat of her diet. 
Make her drink freely of rich milk. Give tonics and diges- 
tants to improve the maternal appetite. The addition tO' the 
diet of some preparation of malt or the weaker alcoholic 
beverages containing malt, such as porter, beer, and stout, 
is beneficial. Southworth's soup made by boiling i or 2 
tablespoonfuls of cornmeal in a quart of water, tO' which 
some palatable flavoring has been added, when taken daily, 
is not only an efficient galactogogue, but increases the fat of 
the milk. A proprietary preparation known as Maltropon 
also yields good results. 

Excess of Protein. — Increase the exercise. Increase 
fluids, especially water (2 to 3 quarts a day). Relieve con- 
stipation. Reduce vegetable and animal protein. 

Deficiency of Protein. — Give tonics, as iron and phO'S- 
phates. Lessen the exercise. Lessen water and other fluids. 
See that the diet contains plenty of milk, beef, peas, and 
beans. Give South worth's soup and Maltropon. 

Excess of Sugar. — Remove carbohydrates from the diet 
and prohibit the use of candy and rich desserts. Increase 
the fluid intake. Increase the exercise. Give an occasional 
saline. 

Deficiency of Sugar. — Increase the carbohydrates, espe- 
cially sug-ar. Lessen the amount of water. Lessen the 



platp: TV 






\ 




/ 



Stool of indigestion in the breast-fed. Note white masses (fat and 
protein), mncus. and admixture of green and yellow color. A very com- 
mon and important stool in the breast-fed. It does not call for a 
discontinuance of the breast milk, as so many mothers, nurses, and 
physicians seem to think. If the infant gains in weight, this stool should 
be ignored. It can be made normal by careful regulation of the 
mother's diet, plenty of water, a reduction in her milk, meat, and sugar 
intake, and the administration to the mother of r:ii occasional saline. 
This stool, more than any other, is responsible indirectly for the high 
infant mortality during the first year, as when it appears it is regarded 
as a cause for commencing artificial feeding, and from this time the 
course of many infants is downward. 



HOW TO DRY UP BREAST MILK. 37 

exercise. Order a daily allowance of beer, stout, or other 
malt preparations. 

HOW TO INCREASE THE TOTAL MILK SUPPLY. 

The total quantity of milk may be deficient. The first 
indication is to control psychic disturbances. Any undue 
loss of blood or other of the body fluids must be prevented 
or stopped. At least two weeks' rest in bed after confine- 
ment must be enjoined. Following this the mother must 
secure plenty of rest, and later a sufficient amoimt of gentle 
exercise, together with an abundance O'f easily digested 
food. She shoiuld be made to drink freely O'f water, weak 
tea, and milk. These should be used, together with 

Galactogogues, of wdiicli cornmcal soup {Soiithworth's 
soup) is an admirable one. Maltropon will alsoi increase the 
total quantity of milk. One tablespoonful of this is mixed 
with a glass of cold milk or water and taken three times a 
day. Lutein derived from the corpus luteum of the hog is 
said to give good results. .Placing the infant regularly to 
the breast is an excellent means of stimulating the flow of 
milk. 

If the supply of milk be excessive, caking must be pre- 
vented by regular feeding intervals, the occasional use of 
the breast pump, hand-milking, gentle massage with warm 
oil, and the administration of gentle laxatives, as cascara 
or a small dose of Epsom salts. 

HOW TO DRY UP BREAST MILK. 

This may be necessary on account of the death of the 
infant, the appearance of some contraindication to maternal 
feeding, the age of the infant (after 12 months) or the 
occurrence of some acute infectious disease. In the last 



38 BREAST FEEDING. 

event, if the infant be the victim, it may not suckle the 
breast, but the milk should be withdrawn and fed from a 
bottle. This will materially increase its chances of recovery. 
Practically all fluids must be withdrawn from the diet, 
including particularly water, milk, soups, alcoholic malt 
beverages, coffee, tea, and cocoa. Only a minimum Oif 
water is allowed. A dail}^ saline must be administered. 
The breasts should be emptied by the pump or by manipula- 
tion, and both glands should be entirely covered (excepting 
the nipples) with belladonna ointment. Lint compresses, in 
which holes are cut for the nipples, are applied and the whole 
covered by a snug figure-of-8 bandage suppoi'ting both 
breasts. Should the organs become painful within a few 
hours, the bandage must be loosened or removed, the 
glands emptied by the pump, and the whole dressing re- 
applied. A little milk may remain for months. 

METHOD OF FEEDING INFANTS AT THE BREAST. 

An infant should be placed at the breast immediately 
after birth. The theory that this aids uterine contraction 
seems to have some foundation in fact. From birth up to 
the period of 6 weeks an infant should be fed every two 
hours during the day and twice during the night. The first 
feeding should be given at 6 p.m. and the last at 8 p.m. 
The feedings during the night should be given at I2 mid- 
night and at 4 a.m. If the child awakens oftener, a little 
warm sterile water may be administered. To insure the 
cultivation of the habit of regularity, the child, if sleeping, 
should be awakened for its food during the day. Toward 
the end of this period one of the night feedings should be 
omitted. Each feeding should not occupy more than fifteen 
or twenty minutes. The infant nuist not be permitted to 



m. ATK V 




Stool of dyspepsia. Occurs in both the breast-fed and bottle-fed baby. 
In the former its significance can often be disregarded, if the weight 
remains unimpaired, or the mothers diet may be regulated as in Plate 
IV. In the bottle-fed, institute a hunger period for twenty-four hours. 
Then reduce the fat and the sugar in the formula, and at the same time 
administer the protein mechanically and chemically modified. (See 
text.) 



CONTRAINDICATIONS TO MATERNAL FEEDING. 41 

CONTRAINDICATIONS TO MATERNAL FEEDING. 

A woman's milk may be insufficient in quantity and of 
poor quality. The quality may be good, but the quantity 
may be small. Any or all of these conditions may con- 
stitute a contraindication against maternal feeding if they 
cannot be corrected or if they interfere with the infant's 
nutrition. Painful fissures may cause a temporary suspen- 
sion of nursing. Abscesses of the breast usually contraindi- 
cate breast feeding, as do painful and septic conditions of 
the infant's mouth. Mothers who suffer from, epilepsy, 
nervous exhaustion, chorea, idiocy, profound anemia, tuber- 
culosis, the acute infectious diseases, syphilis oomtracted 
after delivery, and profuse hemorrhage, should not suckle 
their yoimg. A woman whO' has become pregnant while 
nursing her infant should cease doing so, as the strain of 
supplying nourishment to both fetus and child, besides her- 
self, is too great. Menstruation, also, is regarded by some 
as a contraindication to breast feeding. This is altogether 
a question of the individual, and, if the child's nutrition and 
digestion are not disturbed, menstruation, per se, should 
not prevent the infant from nursing, A woman suffering 
from piuerperal eclampsia or Bright's disease should not 
nurse her child. Malignant disease contraindicates maternal 
feeding. The breast should be withdrawn, temporarily, 
from a nursling suffering from acute alimentary intoxica- 
tion. The physician should hesitate long before he advises 
the withdrawal of the breast. Each case is a law untO' itself 
and must be decided on its merits. Tuberculosis and 
chronic valvular disease, with broken compensation, prevent 
nursing. 

An infant born of a syphilitic mother should be nursed 
by that mother even if it shows no external evidences of 



42 BREAST FEEDING. 



1 



syphilis. It cannot be infected, not on account of immunity, 
but because the child probably has latent syphilis, as 
would be shown by a positive Wassermann reaction (Pro 
f eta's law). So, too, a woman apparently free of syphilis 
should nurse her babe if it be markedly infected. She will 
not become infected (Coilles's law). The reason of this is 
because she, too, has latent syphilis, as sho'wn by a posi- 
tive Wassermann reaction. Thus a scientific explanation 
for both these laws is available. In the first instance, if she 
contracts syphilis after the birth of her babe, nursing must 
necessarily be discontinued. The susceptibility of the infant 
under such circumstances is apparent. 

HYGIENE OF THE NURSING MOTHER. 

Many women who object to nursing do' so from the 
belief that they thereby surrender themselves for a period 
of twelve months tO' a lonely existence, devoid of all pleas- 
ure and social intercourse. This is an erroneous idea, and 
it becomes the physician's duty to make plain to the mother 
her obligation to her child. From the day of conception, or 
from the time she comes under her medical advisor's care, 
every prospective mother should have inculcated within her 
a desire to nurse her infant. Mother-love, often absent 
during the first period of gestation, gradually develops in 
most women as the day of labor draws near. To this the 
physician should appeal, and make known to his patient the 
dangers and vicissitudes of artificial feeding even at its 
best. 

Many women resort to bottle feeding through igno*- 
rance, or through the enticing advertisements to; be found 
in medical journals and upon the labels of proprietary foods. 
These make infant feeding an easy matter, setting at naught 



HYGIEN^E OF THE NURSING MOTHER. 43 

the work of some of the best minds of the profession ; and 
the eager mother, in her zeal to raise her infant with the 
least care, discovers her mistake when it is too late, when 
her child, with a fatal pneumonia, or a mortal attack of 
summer diarrhea, or other acute infectious disease, suc- 
cumbs because it did not have the vital force to resist the 
disease — because it was not breast-fed ! The physician 
should, therefore, preach the gospel of maternal nursing 
day in and day out. By doing so, he not only fulfills his 
duty to his patient, and stands as the defender of helpless 
infancy, but renders invaluable service to his State. By 
doing less he fails in the fulfillment of his mission. 

Between the nursing periods the mother should spend 
her leisure in useful and healthful recreation. She should 
indulge regularly in gentle outdoor exercise. Reading and 
participation in any desirable pastim.e should be en- 
couraged. Rest is essential to her well-being, and mental 
excitement, fear, and worry are to be avoided. She should 
partake freely of easily digestible and nutritious foods, and, 
if accustomed to a glass of beer or light wine with her mid- 
day meal, this should be permitted. Intemperance, how- 
ever, in all things must be interdicted. Daily bathing and 
a perfect digestion are conducive to a sufficient and nutri- 
tious supply of milk. 

Care should be exercised in administering drugs to the 
nursing woman. Certain medicines are eliminated in the 
milk, and exert their physiologic effect upon the infant. 
Therefore such drugs as the saline purgatives, morphin, 
colchicum, belladonna, arsenic, antimony, mercury, and the 
io'dids should be administered cautiously, if at all, to the 
lactating mother. The care of the nipple, as indicated else- 
where, should also engage the attention of the physician. 



44 BREAST FEEDING. 

BREAST FEEDING DURING ILLNESS OF MOTHER 
OR CHILD. 

Whether or not breast feeding is to be continued under 
these circumstances is largely a problemi that must be de- 
cided upon the merits of the individual case. The attitude 
of the physician, however, had best be conservative in most 
instances. Undue haste by needlessly sacrificing the milk- 
supply and hazarding the health and life of the infant may 
lead to disaster. Reference is here made especially to the 
beginning of an acute illness in the mother, in which the 
milk, as a rule, should not be withdrawn until the diagnosis 
has been made, or if an acute infectious disease be reason- 
ably anticipated. The child's safety then demands imme- 
diate removal. The maternal illness may last but a day or 
two, and keen disappointment will follow hurried advice to 
feed the baby otherwise than by the breast. If it be advis- 
able — for instance, if a surgical operation of minor impor- 
tance must be performed — tO' withhodd maternal milk for 
twenty-four or forty-eight hours, then the infant may be 
placed upon a weak milk mixture or condensed milk. After 
a day or two' it is an easy matter tO' rehabilitate the flow by 
the administration of fluids, cornmeal soup, and Alaltropon. 
It is especially in cases of this t}^e, and in the harmless 
digestive disturbances of the breast-fed, that the physician 
can rise above the ordinary level by recognizing and meet- 
ing his opportunity for conserving the maternal milk- 
supply, while his colleagues of less discernment will 
thoughtlessly sacrifice it. 

Illness in the infant is rarely a cause for stopping the 
breast. Septic conditions of the mouth and throat, or an 
acute infectious disease may be a good cause to remove the 



WET-NURSING. 45 

infant from the breast, but not from the breast milk. It 
should be pumped out and fed by the bottle or dropper. 

WET-NURSING. 

Next to maternal feeding, the milk of a healthy wet- 
nurse is undoubtedly the safest food for an infant under 
I year of age. The selection of a wet-nurse should be left 
to the medical attendant, who must subject her to a rigid 
physical examination before she is accepted. Her family 
history should be carefully scrutinized and her past and 
present medical history examined. A woman, the off- 
spring of tuberculous, syphilitic, or cancerous parents, must 
be rejected. Her health should be perfect. She should 
have sound teeth, normal mucous membranes, good diges- 
tion, healthy lungs, and a sound heart and normal kidneys. 
Her skin must be free of all suspicious rashes, and her 
venereal and child-bearing history carefully examined. A 
W^assermann test must be performed on every applicant 
for the position of wet-nurse. If she has frequently aborted, 
or has given birth to many stillborn children, she should be 
rejected. Her milk should be analyzed in order to estab- 
lish its nutrient qualities. This is not always necessary, as 
the health of her own infant will usually give sufficient in- 
formation as to the quality of her milk. Her breasts should 
be normal and well developed, free from rhagades, ulcers, 
and malignant disease. 

A nurse w^ho is suffering from any form of infectious 
or suppurative disease, however slight it may be, should 
not be engaged. The same applies to one whO' is 
irritable, nervous, epileptic, or choreic. She should have 
a just appreciation of her duty and a sincere love for chil- 
dren. She need not be especially intelligent. Probably the 



46 BREAST FEEDING. 

best test for a wet-nurse is the condition of her own child, 
which should be healthy and thriving. If possible, other 
things being equal, a multipara should be given preference, 
although a primipara need not be rejected for this fact 
alone. As a rule, however, young women of 17 or 18 make 
poor wet-nurses. 

In the family whoi has engaged her, a wet-nurse oc- 
cupies a peculiar position. If a good nurse, her services are 
often invaluable, a fact which should not be too strongly 
impressed upon her or she may turn tyrant. She should be 
treated with kindness and courtesy, be well-housed, well- 
fed and well-clothed, in addition tO' the ordinary compensa- 
tion which she receives. The same care should be accorded 
her as to a nursing mother, and she should be made to adopt 
the same hygienic and prophylactic measures which pertain 
to the mother, taking sufficient rest, outdoor exercise, and 
diversion. 

Should her milk disagree with the infant, either 
in its digestibility or in its capacity tO' supply sufficient 
nourishment, as evidenced by the infant's weight and 
strength, she should be discharged and another nurse sub- 
stituted. A syphilitic haby should not he permitted to nurse 
a healthy wet-nurse. Care shotuld be exercised that she does 
not slight her charge by giving all her milk to her own 
infant. 

Indications. — Wet-nursing is urgently useful in the care 
of premature infants, in cases of very weak infants with 
whom no modification of cows' milk will agree, and who 
are threatened with, or are already suffering from, inanition. 
Should the mother die suddenly the outlook for a very 
young though healthy infant becomes brighter, as the 
result of a few months of wet-nursing. 



WEANING. 47 

WEANING. 

By weaning is meant the withdrawal of breast milk and 
the use of stronger food. In reference tO' babies who have 
been reared without the breast, the change means the grad- 
ual cessation of bottle feeding and the addition of solids 
to the diet. Weaning, to be done successfully, must be 
done gradually in most cases. In others, as the result of 
the death O'f the mother, failure of the milk-supply, maternal 
ill-health, or other cause, it must be accomplished rapidly. 
With wasted infants, who, at the age of 20 tO' 24 months 
with many teeth, are still at the breast, no time should be 
lost. Ordinarily weaning shoruld take place between the 
ages of 10 months and 12 months. Some practitioners com- 
mence to give an occasional bottle at 6 months. This, as a 
general practice, is unnecessary. It is best tO' wean after the 
child has cut several teeth. This is an indication, in itself, 
that the gastrointestinal glands have reached a more ad- 
vanced stage of development, and are capable of digesting 
stronger food. The infant should not be weaned while 
cutting a tooth. It should, under no circumstances, if pos- 
sible, be weaned during the summer months. The fall and 
the winter are the best times of the year. The entire time 
occupied before the breast is finally relinquished, under 
ordinary conditions, is about two to four weeks. At first 
one breast feeding is omitted a day and its place is taken 
by a bottle, the composition of the contained milk being 
similar to that of the mother's milk. The infant is kept on 
this for three or four days or a week before another change 
is made. At this time another bottle feeding is substituted 
for a breast feeding, provided the digestive organs of the 
child have not been deranged. The same rule is followed 
and no change is made for another few days. This method 



48 BREAST FEEDING. 

is continued until the bottle feedings entirely displace the 
breast. Now follows the change in the character of the 
milk mixture fed. As the child gains in weight and strength 
and the digestive organs remain normal, the strength of 
the milk mixture is gradually increased from week to. week 
until the formula corresponds to undiluted cows' milk. At 
this period, about the age of 12 to 14 months, the use of 
the bottle is gradually discontinued, and the milk is fed by 
a spoon or drunk from, a cup. The child has now from 8 to 
14 teeth, and soft, farinaceous substances are gradually 
added. Milk-toast, well-cooked rice, oatmeal, mashed baked 
potatoes, tapioca, cream of wheat, farina, meat-juice, the 
wing of a spring chicken, baked apple, stewed prunes, soft- 
boiled eggs, and egg-custard are some of the substances 
which may slowly be added to the diet toward the close of 
the first or at the beginning of the second year. The meals 
are gradually reduced to three a day, with milk or some 
other form of light nourishment given between. The 
fullest meal is given at noon and the lightest at 6 p.m. 

After dentition is complete, other substances may be 
carefully added and the child be permitted to sit at the table 
with the family. vSuch articles, however, as pastries, candy, 
nuts, pork, veal, rich gravies, fancy dressings, bananas, 
fresh bread, hot cakes, muffins, turnips, cabbage, radishes, 
corn, salt and smoked fish and m'cats are tO' be carefully 
eliminated. The child should be taught to chew its food 
slowly and well, and not to overeat. By watchful care and 
judicious management it can be easily taught tO' relish those 
things which are wholesome, and to refuse those which, are 
indigestible. The diet presented in Chapter III, page 140, 
may now be used to great advantage. 



CHAPTER II. 
ARTIFICIAL FEEDING. 



EXPLANATORY AND HISTORICAL. 

The textbook presentation of this subject is most diffi- 
cult inasmuch as long experience is of immense importance. 
Especially is this so at the present time, since the matter is 
by no' means settled. The development of the scientific 
artificial feeding of infants, up to within a few years ago, 
was essentially American. Since then the teachings of the 
German school of pediatrists, represented by Czerny, Keller, 
Finkelstein, Meyer, Heubner, Rubner, Monti, Escherich, and 
others, have made their influence felt on the medical mind. 

At first, analyses of human milk and of cows' milk were 
made and the marked quantitative and qualitative differ- 
ences between the coagulable protein of these twO' milks were 
noted. Under the initiative of Pepper and Meigs in 
America the simple diluting of cows' milk, so- that the vari- 
ous percentages resembled those of human milk, was ad- 
vised and practised. Toi this diluted milk were added milk- 
sugar and cream to make up for their deficiency incident 
tO' the dilution of the cows' milk. These mixtures were 
soon found wanting in many cases, because the dilution and 
additions were not sufficient toi overcome certain intrinsic 
biologic and physical differences, many infants failing to 
thrive upon a milk which nature primarily intended for 
cows, even though the percentages fed accurately equaled 
those of the accepted analyses of human milk. It was 

(49) 



50 ARTIFICIAL FEEDING. 

found, for instance, that a child could digest 4 per cent, of 
fat of human milk, but that the same percentage represented 
by cow-fat often caused disturbance. This fact being recog- 
nized, it was decided, under the leadership of Rotch, of Bos- 
ton, that the basic principle was to recognize digestive dis- 
turbances as dependent upon the fat, protein, or sugar, as the 
case may be, and to^ feed to^ the infant certain definite per- 
centages of each ingredient and to increase or diminish 
them at will according to the indications. From this was 
evolved the idea of the laboratory method, or the percentage 
methodj or the American system of infant feeding. From 
this sprang into existence the Walker-Gordon laboratory, 
which sought to fill the physician's prescription for any 
combination of percentages which he might desire. This, 
however, was soon found to be impracticable for the reason 
that the laboratories were confined to large cities, and that 
the cost of the production of definite percentage mixtures 
was beyond the means of the poor, who' needed it most. 
The idea behind the percentage method seemed to be a good 
one, i.e., to feed gradually increasing amounts of the vari- 
ous ingredients as the individual case required, and tO' 
increase or diminish any special ingredient as the indication 
arose. 

For this reason the so-called home modification of milk 
was devised, and in this connection the work of Chapin, 
Holt, Baner, and others is representative. This embraced 
the so-called' top milk and the milk-and-cream mixture 
methods. They are of immense practical value when in- 
telligently applied, and serve a useful purpose in the evolu- 
tion of scientific feeding. Many physicians seem, however, 
to be unable to thoroughly grasp the details of these 
methods, and experience has shown that as good results can 



EXPLANATORY AND HISTORICAL. 51 

be obtciined by the simple dilution of whole or of skimmed 
milk. This method will be described as we proceed. 

Later it developed that any modification whicli failed to 
recognize the physical difference between the calcium para- 
casein (curd) of human and that of cows' milk would likely 
fail unless something" were done to render the curd of the 
latter more pregnable to the digestive juices by causing it to 
be broken up into, particles resembling the coagulated flocculi 
of human milk. Jacobi years ago, and Chapin more re- 
cently, advocated the addition of cereal decoctions or thin 
gruels made from barley, oatmeal, rice, etc., to dilute the 
milk instead of plain water. Chapin recommended that* 
these cereal waters be dextrinized. Since then other meth- 
ods of dealing with the coagulable protein, which will be 
described later, have been evolved. Still, in spite of care- 
ful percentage manipulation and the attempted adaptation 
of the milk to the individual's digestive capacity, failures 
were numerous. 

It now came tO' pass that the micro-OTganisms were 
regarded as the important causes of mischief, and that every 
percentage formula might fail unless the basis of it was 
germ-free milk. From this arose in succession the advocacy 
of sterilized, pasteurized, and of certified milk. Under the 
impetus given by Coit, milk commissions exist in nearly all 
the large cities and towns of America, and clean milk 
(certified milk) is regarded as an essential of successful 
feeding. 

More recently, the Germans have adopted the so-called 
caloric method of feeding. This seeks to provide a suffi- 
ciency of heat units as required by the weight of the child. 
At least 45 calories for every pound of Aveight are regarded 
as necessary. The Germans ignore the percentage composi- 



52 ARTIFICIAL FEEDING. 

tion O'f the mixture. In this their proposal is weak, since 
it fails to attempt tO' recognize the particular ingredient 
which may be at fault in an individual case. It has been 
well said that the number of calories necessary may be rep- 
resented by a ham sandwich, and yet the infant could not 
digest it. The German school alsoi denies the etioloigic 
influence of the curd as a factor in indigestion, and of 
micro-organisms as the cause of summer diarrhea. They 
regard the fat as a chief offender, the protein as harmless, 
and look upom the fermentation of milk-sugar as the chief 
cause of this frequently fatal disorder of the heated season. 
While the German idea in a sense simplifies the problem, 
many of their claims have not been substantiated clinically, 
at least in America, and their plan of feeding can, be miade. 
as dogmatic and unindividual as it is claimed that the per- 
centage method of feeding is. The points of advantage and 
of disadvantage will be emphasized in the text as the 
problems present themselves. 

It can be readily realized that the subject is far from 
settled, that no textbook outline of it can make a successful 
feeder of the novice. What is necessary in each instance is 
individuaHzation and experience. The fo'rmer is absolutely 
the keynote of success. ''What is meat for one is poison 
for another" applies nowhere with such force as in the 
artificial feeding of infants. In the following presentation 
no claim is made to originality. Facts will be stated as they 
have been learned from personal clinical observation ob- 
tained in an extensive hospital experience here and abroad, 
and in private work and from contact with eminent 
authority. In some instances it may be necessary to plead 
guilty of being ultra-conservative and, perhaps, even un- 
scientific. The other's right tO' his view is recognized, nor 



CHEMISTRY AND PHYSICS OF COWS' MILK. 53 

is it denied that other methods are productive of as good 
results in the hands of their advocates. Lil^erality of viev^s, 
however, and the elastic interpretation of facts and, above 
all, absolute individualization which the two former insure 
whatever the method employed, are claimed to be essentials, 
if the physician would become a successful feeder. 

SUBSTITUTES FOR HUMAN MILK. 

For this piu-pO'se the milk of lower animals has been 
appropriated, and means sought tO' adapt it to human needs. 
The choice of animal depends considerably upon circum- 
stances and the environmental influences of the country. 
Almost universally cows' milk has been employed, although 
use has also been made of the milk of goats, asses, and 
mares. Of the last three, the first alone is used with any 
great frequency, and largely in rural districts and among 
the foreign population. The composition of goats' milk 
follows : — 

rer cent. 

Fat 4-50 

Sugar 4.00 

Protein 4.50 

Mineral matter 0.60 

Total solids i3-6o 

Water 86.40 

This approaches the character of co-ws' milk and, like the 
latter, is deficient in sugar and richer in protein than human 
milk. The curd is finer than that of cows' milk. 

CHEMISTRY AND PHYSICS OF COWS' MILK. 

Like human milk, the composition is not uniform. It 
varies in the same cow at different periods of the milking, 
and varies in the different udders. Thus the composition of 
the milk of a single cow might differ considerably from that 



54 ARTIFICIAL FEEDING. 

of an entire herd. The practical uniformity in compO'sition 
of herd milk makes it more preferable for general purposes 
than that of a single cow. However, the danger of tuber- 
cular infection, foir obvious reasons, is less fromi the milk 
of a single cow, properly examined. The composition also 
varies v/ith the type of cow. Some cows are better adapted 
to infant feeding than others. Thus the Jersey and the 
Guernsey furnish milk rich in fat (over 5 per cent.) and 
one in which the fat emulsion is less perfect than in the 
milk derived from' a Holstein-Friesian or the Ayrshire. 
The former furnishes milk relatively low in fat (less than 
3 per cent.) and protein as well (less than 4 per cent.). 
The milk from the latter is rich in protein (over 4 per cent.) 
and weaker in fat (slightly under 4 per cent.). The milk 
from both these types is well adapted to infant feeding. 
The Devon and Durham cows resemble each other in fur- 
nishing a milk of good average richness. 

Cows' milk, like human milk, is an opaque emulsion oif 
fat in a solution of albuminous material, lactose, and mineral 
matter. The color is white or yellowish white. The odor 
is said to be characteristic, and is alsoi determined by disease 
oir by the diet of the cow. Thus, in the spring of the year, 
the odor of grass or garlic is common. The specific gramty 
at 60° F. varies from 1029 to 1034. Its oscillations de- 
pend upon the composition of the milk. The reaction is 
aiT^photeric, leaning toward acid. It becomes acid a few 
boiurs after milking, the acidity increasing with age. The 
addition of preservatives increases the alkalinity. 

The fat of cows' milk contains olein, stearin, and pal- 
mitin. It exists in considerable proportion as volatile fats 
which are readily decomposed. If milk be allowed to stand, 



CHEMISTRY AND PHYSICS OF COWS' MILK. 55 

the fat being the lightest portion of it, rises to the surface ^ 
and is known as cream. 

Cream, therefore, is simply superfatted milk. If the 
cream be removed by skimmdng after it has risen to the 
surface it is known as gramty cream, and the remaining 
portion is called skimmed milk. Gravity cream varies in 
strength, depending upon the length of time permitted for 
the fat tO' rise to the surface and the depth of the layer 
which is removed. Thus, if a quart of milk be allowed 
to> stand for from three to four hours, the upper ii 
ounces will contain approximately lo per cent, of fat, while 
if the upper i6 ounces, or half of the quart, be removed, 
this superfatted milk or cream will contain about 7 per 
cent, of fat. Cream may be removed by the centrifuge 
{centrifugal cream). This cream is much richer, contain- 
ing from 20 per cent. tO' 35 per cent, of fat. 

The amount of fat in whole milk is not constant. Its 
variability has been noted in the different breeds of cows. 
Good milk averages about 4 per cent. The range of 
variability allowed by most milk commissions is between 
3J^ per cent, and 4% per cent. Microscopically the oil 
globules of the fat of cows' milk are seen to be large 
(Fig. 7, II). The caloric value of the fat is 9. 

The protein exists in solution as calcium casein (for- 
merly caseinogen) and as lactalbumin and lacto globulin. 
Other protein substances of less importance are present, but 
have no general practical interest. If cows' milk be acted 
upon by rennin or by the gastric juice in the presence of 
body temperature it coagulates into a solid mass. From 
this mass will exude a perfectly clear, colorless fluid, and the 
mass will contract into a tough curd. The colorless fluid 
is known as ivhey, and contains principally the so-called 



56 ARTIFICIAL FEEDING. 

ivhey-proteins or soluble proteins — lactalbumin and lacto- 
globuUn, as well as the salts of milk and the sugar of milk — 
lactose. During the process of separating from the curd 
some little fat is carried along. Although, theoretically, 
whey should contain no fat, practically it does. The com- 
position of whey is variously given by chemists. An 

average analysis follows : — 

Per cent. 

Protein 0.94 

Fat 0.96 

Lactose 549 

Salts 0.48 

Water 92.13 

100.00 

Thus it may practically be regarded as a 5 per cent, solu- 
tion of milk-sugar containing i per cent, of whey-proteins 
and I per cent, of fat. 

Lactalbumin and lactoglobulin constitute about one-third 
or one-fifth of the total protein. The former resembles 
serum albumin and the latter serum globulin. 

The coagulable portion of the protein remaining is 
known as the curdj or calcium paracasein (formerly casein), 
and constitutes the large part of the albuminous content 
(about two-thirds or four-fifths). When coagulation 
occurs the curd, which is tough, leathery, and dense, con- 
tains within its meshes fat globules, some lactose, and 
mineral salts. The amount of combined protein, as the fat, 
is variable, but in good milk it averages about 4^ per cent. 
A variation of from 3 per cent, toi 4 per cent, may be 
regarded as within the normal limits. The caloric value of 
the combined protein is 4. 

Lactose constitutes the main carbohydrate. It is a di- 
saccharid. It is readily changed tO' lactic acid by the lactic 



CHEMISTRY AND PHYSICS OF COWS' MILK. 57 

acid bacillus. It crystallizes into hard, white prisms. It is 
less sweet than cane-siig-ar (weight for weight) and is 
soluble in 6 parts of cold water. It is not fermented by 
yeast. It reduces Fehling's so'lution. When acted upon by 
dilute mineral acids it is changed to dextrose and galactose. 
The lactose o-f commerce is obtained as a by-product in the 
manufacture of cheese by the evaporation of whey. It is 
identical in composition to the lactose of human milk, but 
it is unclean and requires sterilization. Cows' milk contains 
about 4 per cent, of lactose, which has a caloric value oi 4. 

The mineral constituents consist principally of the 
phosphate of potassium, sodium, calcium, and magnesium, 
together with the chlorids of potassium and sodimii. Iron 
is found in less quantity than in human milk. It is in 
organic combination with nuclein. Milk contains about 
0.75 per cent, of mineral matter. 

Bacteria. — Some of the bacteria found in milk are patho- 
genic and others are not. Of the former the more common 
are the tubercle bacillus, the bacillus of typhoid fever, and 
the bacillus of diphtheria. Epidemics of scarlet fever have 
not infrequently been traced to a contaminated milk-supply. 
Local disease of the udder may cause the entrance of the 
different varieties of streptococci, staphylococci and more 
rarely of anthrax bacilli. The commoner non-pathogenic 
varieties found are those belonging tO' the lactic acid and 
the colon groups. The total solids, including fat, protein, 
lactose, mineral constituents and bacteria, average about 
13^ per cent. The remainder is zvater. 

The microscopic appearance shows the fat globules tO' be 
large and floating in an opaque fluid. So^me epithelium and 
a few leucocytes may be present and are to be regarded 
as normal (Fig. 7, II). Any increase in these indicates 



58 ARTIFICIAL FEEDING. 

disease, usually inflammation of the udder, and renders the 
milk unfit for food. Bacteria are readily recoignized by 
staining, or they may be seen in the fresh specimen. For 
positive identification they must be cultured, coilonized, 
isolated, and stained. 

Sources of Adulteration and Contamination.— Milk oc- 
cupies the dual position of being the bottle babies' best friend 
and worst enemy. The latter is brought about by con- 
tamination and adulterations, either accidental or intentional. 
The initial source of contamination occurs at the time of 
milking, and one of the most important is the dust-laden 
air of the stable. Anyone who has ever visited a farm and 
watched the ordinary farmer milk his cows and then, when 
through, to see him strain it through a coarse strainer and 
then note that left in the latter are particles of straw, 
manure, dust, and hair, will be able tO' appreciate how 
readily milk may become a carrier of disease. 

The cows are usually kept in poorly ventilated stables, 
in stalls provided only with straw beds, and with noi means 
of collecting the manure, which becoming entangled in the 
straw and, drying, is thrown into the air, by the kicking and 
shuffling of the animal. Flies are not excluded, and the 
udder too is covered with dry manure and milk. The 
farmer does his milking intO' an open, perhaps unwashed, 
bucket or one rinsed in spring-water. The atmosphere is 
dust-laden and his hands are probably unclean. The cow 
may have an ulcerated, inflamed, or even tubercular udder. 
From his bucket the milk' is placed into an indifferently 
cleansed can, after straining as indicated — the gross par- 
ticles having been removed, but the micro-organisms all 
passing through. The cans are placed in the spring-hoiuse, 
in which the temperature, while low, is not sufliciently so to 



CHEMISTRY AND PHYSICS OF COWS' MILK. 59 

prevent bacterial growth. Before being placed in the cans, 
if the farmer be unscrupulous, the milk may be watered or 
preservatiAXS introduced, or chalk added to whiten it. It 
is now transported to the railway station, where it awaits 
the early train. In the mean time bacterial growth can con- 
tinue. It reaches the city, where, on the unloading plat- 
form, it may be exposed to the sim for hours. This again 
favors the further development of micro-organisms. Ex- 
posure again occurs in the milk-house where it must be 
bottled, and, unless the establishment is run in a hygienic 
rruanner, the improperly washed bottles and the hands of the 
workmen may be a further source of contamination. In the 
early morning it is delivered on the doorstep of the consumer, 
where it remains exposed for a few hours to^ a gradually 
rising temperature, and in summer months to a very high 
degree of heat. 

In the home the sonrces of additional infection are 
many. Danger may arise from improper icing, improperly 
sterilized receptacles, bottles, nipples, and the water used 
to dilute may be unfit for this purpose. The formula, even 
if properly made, may not be carefully iced, and bacterial 
growth continues uninterrupted. In some cases the milk is 
no!t bottled, but sold direct to^ grocery stores and thence to 
the consumer, being dipped from the can into a pitcher. 
Infection readily occurs in this manner. Milkmen have 
been seen to drink milk from the lid of the can while en 
route in the city streets, and to return what they did not 
want to the can. This, not alone filthy habit, is exception- 
ally dangerous in that the likelihood of tubercular contami- 
nation is imminent. Another unclean habit is for the 
mother or nurse to suck the milk from the nursing bottle 
in testing the temperature before feeding it to the baby. 



60 . . ARTIFICIAL FEEDING. 

It is readily seen, therefore, that from the time the milk 
leaves the cow until it reaches the consumer it is exposed to 
many and varied sources of infection. 

Analysis of Milk and Detection of Chemical Adulter- 
ation. — Analyses for the various normal constituents of 
cows' milk are conducted as for human milk (Chapter I). 
The average composition of normal milk may be stated as 
follows : — 

Reaction, Amphoteric or Acid. 

Specific gravity 1029 to 1034 

Protein 3-50% to 4.50% 

Fat 4.00% 

Water 4.00% 

Mineral matter 75% 

Total solids 12.25% to 13.25% 

Water 87.75% to 86.75% 

Watering of Milk. — Water is added tO' milk by dis- 
honest dairymen and dealers, tO' increase the volume. Aside 
from the moral aspect of the procedure, this is a very 
dangerous practice. It dilutes the various chemical con- 
stituents, thereby destroying the nutritive qualities of the 
milk. Besides it adds to the milk millions of micro- 
organisms, many oif which may be pathogenic. In the same 
class belong those cases where skimmed milk is sold for 
pure cows' milk. An easy and simple method of detecting 
these practices, aside from noting the physical character of 
the milk, is by the use of a small hydrometer. Skimmed 
milk, when allowed toi stand, will coiUect no' cream on the 
surface. It is paler than pure milk and has a higher specific 
gravity, because the cream, the lightest constituent, has 
been removed. Watered milk is pale bluish in color and of 
a low specific gravity. Milk may be both skimmed and 
watered at the same time, exhibiting a normal specific 
gravity. These adulterations can usually be detected with 



CMECMISTRV AXD PHYSICS OF COWS' MILK. 61 

the naked eye or are discovered by chemical analysis. For 
practical puqDOses the lactometer (ordinary hydrometer) 
is very convenient, and is a rapid means of detecting a good 
from a bad milk (Fig. 9, page 19). 

Preservatives. — Preservatives are added to milk to keep 
it fresh, to prevent the growth of micro-organisms, and to 
save, to the dealer, the expense of extensive icing. Among 
the preservatives, formaldehyd is the most extensively em- 
ployed. Boric acid, benzoate of soda, borax, bichromate of 
potassium, and salicylic acid are used, but tO' a much less 
extent. Chalk is added at times, to color the milk white 
after it has been watered. 

Formaldehyd is usually employed in the form of for- 
malin, which is a 40 per cent, solution of formaldehyd gas 
in water. Only a few drops of this solutioin need be added 
to a pint of milk to keep it sweet. Formalin is rarely added 
in sufficient quantity to be tasted. It may be detected by 
two principal tests : (a) Dilute a small quantity of milk with 
an equal amount of water. Pour this gently upon some 
strong sulphuric acid in a test tube. If formaldehyd be 
present, there will appear a violet color at the line of con- 
tact. If formaldehyd be absent, a greenish or brownish ring 
will be formed. Hydrochloric acid causes the casein of 
milk to appear yellow in the presence of formaldehyd. 

{h) Distil a small quantity of milk and tO' the distillate 
add a drop of a weak solution of carbolic acid in water. 
Gently pour this over some strong sulphuric acid. If for- 
maldehyd be present a red ring is formed at the line of 
contact. 

Borax and boric acid are detected, qualitatively, in the 
following manner: (a) A small quantity of milk is diluted 
with an equal amount of distilled water, and then slowly 



62 ARTIFICIAL FEEDING. 

evaporated to dryness. The residue is shaken with alcohol 
and filtered. The filtrate is then ignited and burns with a 
green flame. 

(b) If a piece of tumeric paper be immersed in a 
solution containing boric acid, upon drying it turns to a 
reddish-brown color. 

Toi detect salicylic acid mix a small amount of the sus- 
pected milk with an equal quantity of water. Add a few 
drops of acetic acid, and apply gentle heat to the boiling 
point, but do not boil. Add an excess of pure mercuric 
nitrate. The casein is coagulated. Filter. Evaporate the 
filtrate. Agitate the residue with ether. Evaporate the 
ethereal extract. Touch the residue with a few drops of 
tincture of ferric chloride. If salicylic acid be present there 
occurs a violet color. 

Potassium bichromate may be detected by coagulating 
the milk with a few drops of acetic acid and gentle heat. 
Filter. To the filtrate add a few drops of a solution of 
lead acetate. A yellow precipitate of lead chromate indi- 
cates the presence of the preservative. 

Milk containing chalk is alkaline in reaction and effer- 
vesces upon the addition of hydrochloric acid, setting free 
carbon dioxid gas. The crystals of calcium carbonate may 
be detected by the microscope. 

Hygienic Care of Cows. — While not attempting to deal 
with this subject in the comprehensive manner which it 
merits, a work of this kind that failed to emphasize the 
great importance of it would be incomplete. All coiws 
should be tested with tuberculin and mallein. The cow- 
bams must be made sanitary. The stalls must be kept 
clean and free of all dust and manure. The food must be 
selected and clean and regularly given to prevent indiges- 



CHEMISTRY AND PHYSICS OF COWS' MILK. 63 

tion. The animals should be regularly watered. The 
udders are to be kept clean, especially before milking, 
which should be done in a separate dust-free room. Plenty 
of rest, and exercise in the green pasture are essential. 
Under no circumstances should the cows be frightened or 
teased. In winter they are to be housed in such a manner 
that they do not suffer from cold. 

Collection and Care of Milk for Marketing. — Cows must 
all be free from tuberculosis and glanders. The cow-stable 
should be well ventilated. The floors should be boarded. 
The cows should be curried and groomed daily. The fecal 
and urinary discharges should be remoived from the stall 
at once. Attendants should be free of disease, and scrupu- 
lously clean in person and of good disposition. Persons 
who have just recovered from typhoid fever should not be 
employed. Privies and urinals receiving human excrement 
must be far removed from the cows or the milk-room. If 
possible the milking should be done in a separate compart- 
ment, into which the cov^ is taken after the udder has been 
thoroughly cleansed with soap and water, rinsed and dried. 
The milker's hands are prepared by thorough scrubbing and 
immersion into an antiseptic solution. The milking is done 
intO' the spout of a covered can upon which the milker sits 
(Fig. i6). In the spout is a metal filter. Previous to use, 
the can, and especially the filter, should be scrubbed with 
soap and water, rinsed, and scalded with live steam. The 
milk is at once carried into the cooling room, where it is 
placed into a special, previously sterilized cooling apparatus, 
which permits it to flow intO' sterilized quart bottles. The 
bottles are closed w^ith sterile caps and at once iced. The 
milk has not been touched by human hands and has reached 
a refrigerating temperature within half an hour after leav- 



64 



ARTIFICIAL FEEDING. 



ing the cow's body. It is shipped to the city iced and kept 
so until it reaches the door of the consumer. This it should 
do in not less than twenty-four hours. It may even be 
delivered iced in small individual boxes. 

Care of the Milk in the Home. — On the doorstep of the 
consumer great damage may often be done to the very 
cleanest milk. What organisms have entered at the time of 
milking may rapidly increase if the bottle be permitted to 
remain long exposed to the sun. It should be immediately 




Fig, i6. — Proper can used in milking cows. (Dairyman's 
Supply Co., Philadelphia, Pa.) 



taken into the house and iced until needed. When making 
modifications every possible means of cleanliness and 
sterilization with reference to apparatus and diluents should 
be carefully managed, otherwise a perfect milk may be- 
come contaminated. After the formula has been made, care- 
ful and continuous icing are essential. In other words, the 
requirements necessary to secure a good milk, aside from 
its proper hygienic care in the home, are perfect dairy 
hygiene and healthy cows, quick refrigeration and ship^ 
ment to the city, or, as someone has said, it is important 
to "shorten the time between the cow and the baby." 



I'F.ATr: VI 




Constipated, greasy stool of artificially fed infant. This stool is due 
to the administration of too much fat. It is foul-smelling (like Lim- 
burger cheese), and is commonly accompanied by a stationary weight 
and an ammoniacal urine. Reduce or omit the fat in the formula or 
practice the other methods for treating fat intolerance. (See text.) 



ORDINARY, NURSERY, AND CERTIFIED MILKS. 65 

Clean milk is an essential to successful infant feeding, and 
it matters not how well may be adjusted the percentage or 
caloric requirements of the food, it will not only fail in its 
purpose, but it will accomplish serious damage as well, 
unless this is actually secured. 

Consumable milk as marketed today may be readily 
classified under three types : — 

ORDINARY MILK, NURSERY MILK, AND 
CERTIFIED MILK. 

Ordinary Milk. — This is milk that is sold from cans in 
the shops, or fromi wagons, or may be bottled at the city 
distributing station after shipment in large cans. It is con- 
stantly exposed to contamination and is scarcely a fit food 
for infants. The bacterial count is high. It should never 
be given unboiled. It sells for 8 cents a quart in 
Philadelphia. 

Nursery Milk, so called, represents an attempt to pro- 
duce a higher grade or cleaner milk. It is bottled on the 
farm and usually contains a smaller number of bacteria than 
ordinary milk. It should never be fed unpasteurized or un- 
sterilized. It costs about 12 cents a quart. 

Certified Milk represents an attempt at the production of 
a perfectly clean milk. Coit, of Newark, was the first tO' 
conceive the idea of a milk commission in conjunction with 
the County Medical Society, or independent of it. The 
milk commission has in . its employ a chemist and a bac- 
teriologist whose duties are to> visit the dairy of anyone 
who may enter into an agreement with the commission. At 
stated, but unannounced, intervals the chemist and bac- 
teriologist inspect the dairy and examine the milk. If it be 
up to the standard as decided upon by the milk commission. 



66 ARTIFICIAL FEEDING. 

the dairyman receives a certificate^ — hence certified milk, 
which simply means the purest and most wholesome milk 
obtainable. If the requirements are not met the certificate 
is withheld, after giving the dairymian ten days in which 
to correct the error. The milk commission requires perfect 
dairy hygiene and demands a certain bacterial standard. 
This has not been imiform with all commissions, some 
allowing 10,000 bacterial colonies^ and some 20,000 or more 
per cubic centimeter. The American Association of Medical 
Milk CoimmissioBers has adopted 10,000 as the maximum 
number allowed. As far as possible the nature of these 
organisms should be determined, as the presence of a few 
pathologic ones (typhoid fever, for example) would do 
more damage than many non-pathogenic bacteria. In order 
to keep the number as low as possible the milk must not be 
over 30 hours old before it is received by the consumer. 

Besides the bacteriologic requirements, the milk must 
contain not less than 33/^ per cent, of fat and preferably 4j^ 
per cent.; cream not less than 18 per cent. Fromi 3 per 
cent, to 4 per cent, of protein must be present. There 
must be no preservatives, and the specific gravity is re- 
quired to be between 1029 and 1034. 

The commission also supervises the health of* the 
employes. 

It will be seen, therefore, that the cost of production of 
certified milk is greater than under ordinary circumstances. 
For this reason this milk sells from 16 tO' 24 cents a quart. 

"May certified milk be fed raw?" is a common query. 

1 The terms "bacteria" and "bacterial colonies" are commonly used 
interchangeably. This is an error, as the colonies are counted and not 
the bacteria. This distinction is important, as it can be readily ap- 
preciated that there is quite a difference between 10,000 bacteria and 
10,000 bacterial colonies. 



HOW COWS' MILK DIFFERS FROM MATERNAL. 67 

Theoretically it should be perfectly safe and is so during- 
eight months of the year. During June, July, August, and 
September, in order to make assurance more certain, it is 
reconimended that even certified milk should 1)e pasteurized 
or sterilized in the home. 

HOW COWS' MILK DIFFERS FROM MATERNAL MILK. 

The proper adaptation of cows' milk entails a knowl- 
edge oif the biologic, chemical, and physical differences be- 
tween it and human milk. 

The reaction oi cows' milk to litmus-paper is amphoteric 
or acid. By the time it reaches the consumier it is acid, 
owing tO' the formation of lactic acid. That of human milk 
is amphoteric, leaning toward alkaline. The specific gravity 
of cows' milk is 1029 to 1034, that of human milk 1031. 
The greatest difference between these twO' milks is in the 
character and the quantity of the protein. When cows' milk 
is acted upon by rennin or pepsin, at body temperature, the 
coagulable portion (calcium paracasein) derived from cal- 
cium casein (caseinogen) clots in large, lumpy, tough 
curds. The liquid portion contains lactalbumin and lacto- 
globulin. It has been shown that the calcium casein of 
human milk is changed by rennin intO' fine, flaky curds of 
calcium paracasein. The amount of combined protein 
foimd in cows' milk equals about 4.5 per cent., two-thirds 
of w^hich is coagulable by rennin. The total amount in 
human milk is 1.5 per cent., of which but one-fourth is 
coagulable by rennin. The fats existing in the twO' milks 
are about equal in amount, but those of cows' milk are more 
volatile and irritating. There exists in cows' milk only 
abont one-half as much lactose. Cows' milk is practically 
never sterile. It may be sterile in the cow's udder, but as 



68 ARTIFICIAL FEEDING. 

soon as it strikes the air or the surface oif the teat it be- 
comes contaminated. It also receives micro-organisms 
from the hands of the milker, sores upon the udder, the 
milk cans and, sometimes, from the water which is added 
to dilute the milk by dishonest dealers. The organisms 
gain entrance into the milk by the medium of flies, stable 
dust, and manure. They may be pathogenic or non-patho- 
genic, depending upon their source. They multiply rapidly 
and may equal 20,000,000 colonies! per cubic centimeter. 
They constitute a dangeroius factor when cows' milk is em- 
ployed as an infant food, playing an important role in the 
production of the summer diarrheas and other gastroin- 
testinal complaints. The following table shows the differ- 
ences detailed above : — 

Cow's MILK. Human Milk. 

Amphoteric or acid Reaction Alkaline. 

1029 to 1034. Specific gravity 1029 to 1031. 

4.5% Proteins 1.5 to 2%. 

Clots in large lumpy curds. .Effect of rennin Clots in fine curd. 

4.6 % Fats 3.50 to 4%. 

4.0 % Lactose 6.0 to 7%. 

0.75% Salts 0.20 to 1%. 

13.25% Total solids 11.20 to 14%. 

86.75% Water 88.80 to 86%. 

Never sterile Bacteria Practically sterile. 

THEORY OF MILK ADAPTATION. 

The term, "milk adaptation" is better than ''milk 
modification" for the reason that it at once defines the 
principle upon which the problem' of infant feeding and of 
milk manipulation rests, viz., indizndualisation. A success- 
ful feeder of infants must individualize and not feed by rule 
of thumb. The importance of this one's or that one's 
method of feeding is fast disappearing in sO' far as it wonld 
describe a fixed ^vay of feeding all infants. As a means 



THEORY OF MILK ADAPTATION. 69 

toiward an end, any method tliat will permit of the manipu- 
lation of milk, so that it will fit the requirements of the in- 
dividuali infant, , will live and continue to he a means of 
considerahle help. One may not feed an infant percentages 
of fat, protein, and lactose suitable to its age on calories 
said to be required by its zveight, but o-ne mitst feed per- 
centages of these ingredients that it can digest and calories 
that will cause it to gain in zveight — whether these be less 
or more than the fixed requirements. The best judge of 
the suitability of any formula is the infant itself. If it ex- 
hibits a continuous and regular gain in weight and has a 
good digestion (normal stools and little or no vomiting), 
that is the coirrect formula for it regardless of its composi- 
tion as to quantity or quality. The zveight and the digestion 
are, therefore, the guides as tO' the suitability of any food 
for the individual. 

The first formula prescribed by the most eminent 
dietitian is an experiment. We may start out with the 
idea that we wish tO' give an individual baby, say, 2 
per cent, of fat, 6 per cent, of sugar, and ij^ per cent, of 
protein, and we proceed tO' calculate this in ounces of milk, 
cream, sugar, and water. 'Ts there absolute accuracy of 
these various percentages in the finished product?" We 
do not know. The chances are against it. Any one of 
the various ingredients may, and probably does, vary from 
one-fourth to one-half of i per cent. toO' much or too little. 
The feeding of absolutely accurate percentages is impossible 
and unnecessary. Any conception of percentage feeding 
that regards this as one of the possible advantages tO' be 
gained is fallacious and mischievous. What percentage 
feeding shoidd mean and afford is an easy zmy zjuhereby 
any one of the ingredients of the formula — fat, protein, or 



70 ARTIFICIAL FEEDING. 

sugar — may he increased or diminished, and it is the physi- 
cian's province to determine zvhich of these is at fault by 
studying the symptoms of the individual. What these 
symptoms of the different forms of indigestion are will be 
stated under their respective headings. Recognizing that 
element which is at fault, the physician simply applies 
whatever method oi milk adaptation he may favor to the 
case, and increases or diminishes the ingredient, using the 
figures which represent percentages simply as a guide, not 
caring whether those figures accurately represent the exact 
amount or not. One cannot say that the fat of cows' milk 
is the cause of all digestive disturbances in infancy, any 
more than one can proclaim that infants will tolerate incal- 
culable amounts of the curd of cows' milk ; noir can one lay 
all digestive disturbances to protein or to sugar, or tO' ex- 
cessive caloiry feeding. One cannot affirm that all infants 
must be fed every twO' hours, nor yet every four hours, noir 
that quantities must be regulated by set figures ior the age. 
Here again it is necessary to^ individualize and tO' be guided 
by the digestion and the appetite. 

A glance at the foregoing table will indicate certain 
intrinsic differences between cows' milk and human milk, 
and it appears patent that these must be considered in any 
scheme that would provide, nourishment for the individual 
baby. The most striking feature is that, as it exists in its 
native state, the protein of cows' milk exceeds in amount by 
about three times that found in human milk, and differs 
intrinsically in the nature of the curd. Any system of 
feeding that does not recognize this as an indication tO' feed 
to an infant in its early weeks, an amount of cows' curd less 
than that foimd in human milk, and at the same timie to 
change its physical character, must necessarily fail. Milks 



THEORY OF MILK ADAPTATION. 71 

are suited to the species, and it is undoubtedly true that the / 
curd determines the future character of the gastrointestinal 
tract and prepares it for the food which it will receive in 
adult life. Intestinal development, therefore, depends upon 
the nature oi the curd (Chapin). The curd of cows' milk 
is intended to develop the gastrointestinal tract of a calf 
into that of a cow, and therefoire' is suited to; the digestion 
of a calf, while that of human milk is intended tO' develop 
the guts of an infant intoi those of a man, and is therefore 
suited to the digestive powers of early life. Hence) the 
ooiws' curd must be fed in small amoiunts at first and 
modified in nature, either mechanically or chemically, until 
tolerance is established. The extent of this modification 
again depends upon the digestive capacity of the individual, 
some infants at an early age being able to^ tolerate larger 
amounts of protein than others which are older. 

The curd of bovine milk may be dealt with in several 
ways. The processes employed will be described later, they 
simply being named here. In the first place the coagulable 
protein (calciumi paracaseini) may be eliminated entirely by 
the feeding of whey in instances wherein protein intoler- 
ance exists. The curd may be attenuated, i.e., be made to 
coagulate in the stomach in finer flocculi by the use of cereal 
waters or gruels, — plain (Jacobi) or dextrinized (Chapin), 
— flour ball, or by malt soup. It may further be acted upon 
so as to piass through the stomach without coagulation by 
the addition of sodium citrate (Poynton). Predigestion, or 
pancreatization, and sterilization are other means of render- 
ing the curd digestible. Lastly, mechanical division of the 
curd may be secured by feeding Finkelstein's eiweissmilch 
or buttermilk. 

Unchanged cow-protein is therefore fed in gradually 



72 ARTIFICIAL FEEDING. 

increasing amounts until a quantity is reached that about 
equals or slightly exceeds that found in human milk. One 
must always, however, be guided by the digestive powers 
of the individual. By the time the infant reaches 9 months 
or a year it may receive, if it be healthy, whole cows' milk, 
which means about 4^^ per cent, of combined protein. I 
have met a few instances in which this was safely tolerated 
at 5^ months. 

While occurring in about the same amounts, in both 
human and in cows' milk, it is nevertheless true that the 
fat of the latter is less easy of digestion. The same rule, 
applicable to the protein, therefore applies here. The 
amount of fat fed must be gauged by the individual's ability 
to appropriate it. It is best to start with small amounts 
and tq gradually increase, as a rule never exceeding 4 per 
cent. In most instances infants do better if kept within this 
amount — from 2j^ to 3^^ per cent. Certain infants cannot 
tolerate fat at all. These must be fed skimmed milk, butter- 
milk, eiweissmilch, or the formula may be pancreatized. 
The necessity for fat, however, is urgent, as it provides 
heat and energy and consen^es the proteins of the body. As 
this is also done by the carbohydrates, in instances wherein 
fat intolerance occurs, the deficiency may be made up by 
the addition of starches and sugar. 

The carbohydrates of these two milks are identical in 
chemistry, but differ in amounts. The milk-sugar of com- 
merce requires sterilization. How are we to^ deal with the 
carbohydrates? Personal experience would conclude that 
infants bear sugar well. Physiologically this is substan- 
tiated by the high sugar content of human milk. Sugar 
provides heat and energy. The German idea that milk- 
sugar, per se, is responsible for the initiation of all cases of 



THEORY OF MILK ADAPTATION. 73 

summer diarrhea appears to be overdrawn, althoii^-h the 
withdrawal o>{ sugar in the presence of summer complaint 
undoubtedly does good. So long as micro-organisms infest 
miilk, soi long will their role, either by causing toxic changes 
ini the milk itself or in the intestines of the infant, be quite 
potent. 

Milk-sugar is not the best carbohydrate to add to^ milk, 
for the reasons stated, that it is unclean, and because it re- 
quires sterilization and readily ferments. For years Jacobi 
advocated cane-sugar, which is cheaper, cleaner, more easily 
accessible, and ferments less readily. Its use is attended 
by very little digestive disturbance, and has given universally 
good results. Least irritating of all sugars, and more 
readily digested and quickly absorbed, is maltose. It is 
added in about the same amounts as the other sugars 
(Chapter III, page 137). Immediately after birth, most in- 
fants can tolerate from' 4 to 5 per cent, of sugar. This usu- 
ally may be speedily increased tO' 6 or 7 per cent, and at 
about 9 months is gradually redliced until at a year 4 per 
cent, is reached. This guide miay require variation, as. the 
individual digestion may indicate. 'Those infants which 
bear sugar badly may be fed upon simple dilutions of whole 
milk, without the further addition of carbohydrate, or upon 
buttermilk or eiweissmilch. If the absence of sugar makes 
the food unacceptable to the infant, the sweet taste may be 
supplied by the addition of saccharin, i grain to the quart. 
Every ounce of sugar equals about 120 calories. 

Cows' miilk is deficient in those mmeral substances in 
which human milk is rich. To this latter quality and to the 
antibodies, derived from the mother, human milk probably 
owes its antiscorbutic, antirachitic, and immunising quali- 
ties. In the artificially fed it is necessary to make up for 



74 ARTIFICIAL FEEDING. 

these deficiencies by feeding to the infant, between nursings, 
fruit- juices and beef -juice. These are rich in organic sub- 
stances and materially increase the content of chlorid of 
soda. This has a stimulating effect upon the gastric secre- 
tion, thereby aiding digestion. It is good practice tO' add a 
few grains of common salt therefore to each bottle as well 
(Jacobi). This has been my personal practice for years. 

Human milk is sterile; cows' milk is not. This differ- 
ence must be overcome by securing as clean a milk as is 
possible. This is accomplished by using certified milk or by 
pasteurization or sterilization (pages 91-94). 

The reaction of cows' milk by the time it reaches the 
consumer is often acid. Alkalies are to be added with a 
purpose in view, but not routinely. Sodium citrate, sodium 
bicarbonate, and lime-water are employed. Their special 
indications will be detailed as we proceed. 

Summary. — The various percentages of fat, protein, and 
lactose, as well as the caloric requirements, are tO' be 
adapted to the individual. In addition, animal and vegetable 
juices are necessary. Micro-organisms must be eliminated 
or destroyed. Alkalies may be required. 

METHODS OF MILK ADAPTATION. 

Percentage Feeding. — The various methods of adapting 
cows' milk to the needs of the infant have multiplied so 
rapidly that considerable confusion exists as to which is the 
best. Having stated the basic principle of percentage feed- 
ing, it follows that any method will be suitable that affords 
an easy means of increasing or diminishing the ingredients 
of the milk. Two ways of handling this problem are open 
to practitioners of American cities — the Laboratory Method 
and the Home Method: — 



METHODS OF MILK ADAPTATION. 75 

Laboratory Method. — Tliis is the easiest from the practi- 
tioner's viewpoint, and yet in practice is the least satisfac- 
tory. The physician studies his patient's needs, and writes 
the percentages of the different elements in the milk as he 
determines will supply those needs and be acceptable to his 
patient's digestion. The prescription also states the number 
of feedings and the amount of each feeding, together with 
the nature of the diluent. This is sent to the laboratory. 
The completed formula, either in a single container or in 
individual bottles, containing sufficient food for one feeding, 
properly iced, is delivered to the patient's home each day. 
The physician may change his prescription at any time. 
Laboratories have been established in many of the large 
cities in America by the Walker-Gordon firm, under the 
impetus given accurate percentage feeding by Rotch, of 
Boston. The disadvantage of this method is that it is not 
available in rural districts. It is costly and beyond the 
reach of the middle classes and the poor, who most need 
clean milk. Further, as good results, and perhaps better, 
can be obtained by careful home moidification. 

The following represents a prescription form that may 
be used in laborato^ry feeding: — 



Name Age 

Address Date 

I^ Protein % 

Fat % 

Sugar % 

Alkali % 

No, of feedings Amount of each feeding 

Character of diluent Maltose, saccharose, lactose 

Lime-water Pasteurize ? 

Sodium bicarb 

Sodium citrate 

M.D. 



7(i ARTIFICIAL FEEDING. 

Home Method of Milk Adaptation. — That system of milk 
modification or, better, of milk adaptation is correct which 
gives correct results. The simpler the means by which 
good results are obtained, the better is the method ; for it 
is more readily adopted by practitioners, is more easily 
taught to the mother, and is best for the infant. It has 
therefore appeared to me, after fifteen years of experience 
with nearly all the methods proposed, that the simple dilu- 
tion of whole or of skimmed or of partly skimmed milk will 
yield as good results as the use of top-milks or of those 
formulce derived from some highly complicated algebraic 
equation. By means of the simple dilution of whole or of 
skimmed milk we need not, nor indeed we should not, dis- 
card the percentage nor even the caloric idea. Both are 
founded upon sound scientific reasoning, and both are of 
use provided they do not cause one to^ become narrow and 
dogmatic. Percentages should simply be regarded as rep- 
resenting certain degrees of strength, and the numbers 
employed to represent the percentages should never be con- 
sidered to mean absolutely the exact amount of fat, sugar, 
or protein, as the case may be, as is stated. This is impos- 
sible ; likewise it is unnecessary. The numbers employed to 
represent percentages might just as well be indicated by a 
letter. Thus P. i per cent, and P. 2 per cent, could be 
written Pa, Fb, each advancing letter standing foir a degree 
of strength of protein stronger than the preceding letter. 
The same applies tO' the varying strengths of fat and of 
sugar which may be desired. The idea is not tO' feed accu- 
rate percentages of each ingredient, but to have a means of 
increasing or of diminishing any particular substance which 
the clinical condition may indicate. The same is true with 
reference to the caloric requirements of the individual. Any 



METHODS OF MILK ADAPTATION. 77 

formula may be checked, and thus one will be able in 
the individual case to note whether the particular baby is 
receiving a sufficient number of heat units. 

From the foregoing it must be realized that without 
the use of common sense one need not expect to become 
a successful feeder of infants. The keynote of the whole 
situation is that the individual must be studied from the 
standpoints of his appetite, his strength, his caloric require- 
ments, — above all, from the standpoint of his digestive 
capabilities. He who would be successful must therefore 
be a good reader of stools, and must be able to interpret the* 
macroscopic appearance of the excreta properly, and to- de- 
termine the individual's ability to take care of the fat, sugar, 
and protein. These points have just been detailed on pages 
32-34. It may, however, again be emphasized that the main 
indices as tO' the value of any particular food are a con- 
tinuous and sitbsfanfial z^'eekly gain in weight and normal 
stools. If the latter are present and the infant is receiving 
a sufficient quantity of food, the former must follow as a 
natural consequence. It is inevitable. Therefore the first 
formula would be written about as follows : — 

Skimmed milk 2.5 oz. 

Diluent 17.5 oz. 

Sugar 1 .0 oz. 

Salt I pinch. 

As stated previously, this is an experiment, as all first 
formulae are, even in the best of hands. Upon this the in- 
fant may not immediately gain. Skimmed milk is employed 
in the beginning simply to ''play safe." Fat is a common 
disturber of digestion, and therefore, at the outset, fat is 
temporarily omitted or reduced to a minimum. Our guides 
— the stools and the weight — are now consulted. As just 



78 ARTIFICIAL FEEDING. 

stated, one would not as yet expect a gain. However, it is 
assumed that the stools appear normal and that the infant 
does not vomit. We now proceed cautiously. We employ 
half-skimmed milk in the same proportions as we employed 
the wholly skimmed milk. The mother is instructed to 
remove all the cream, and then to pour back intO' the bottle 
half of that which was removed. The whole is well shaken 
up and the second formula is made up as follows : — 

Half-skimmed milk 2.5 oz. 

Diluent 17-5 oz. 

Sugar i.o oz. 

Salt I pinch. 

It is again assumed that this slight addition of fat causes 
no disturbance. In a day or two the mother is instructed to 
shake up well the whole quart of milk and toi employ a 
formula as follows: — 

Whole milk 2.5 oz. 

Diluent 17.5 oz. 

Sugar 1 ,0 oz. 

Salt I pinch. 

No disturbance occurring, in daily succession we speedily 

change the formula as indicated : — 

Whole milk 4 oz. 

Diluent 16 oz. 

Sugar I oz. 

Salt I pinch. 

And then too: — 

Whole milk 5 oz. 

Diluent IS oz. 

Sugar I oz. 

Salt I pinch. 

From this point onward if the digestion be good the baby 
should commence to gain from, ^4 to i ounce a day or from 
5 to 7 ounces per week. The questions to be answered now 



METHODS OF MILK ADAPTATION. 79 

are: "When shall the strength of the formula be changed 
again ?" and "When shall the amount of each feeding be in- 
creased?" The safest rule toi follow in my Ofvvn experience 
is to make no change until the infant ceases to gain on its 
food. Let a stationary zueight or a slight loss therefore be 
our index for action in a case that has been continuously 
gaining and digesting zijell. 

We may now doi one of three) things, viz., (a) Increase 
the strength of the miilk in the formula, {b) Increase the 
amount of each feeding, (c) Do both. 

The last is bad practice. It is unwise to^ increase 
the amount of the feed when the strength of the formula is 
increased, i.e., it is bad to do both simultaneously. The 
latter should be done a day or twO' after the former, when 
it is seen that the increase in the strength of the formula 
has caused no disturbance. "What should be the size of the 
increment in the milk content of the formula?" and "What 
should be the size of the increment of the bulk of the meal ?" 
The latter will be answered first. The quantity added to 
each meal should never exceed i ounce, and it had better be 
not more than ^ ounce. Thus, if lo meals were given 
daily, this would mean the increase of from, lo to 5 ounces 
in the total bulk of the food per diem. The strength of 
the formula may be increased as follows, meanwhile making 
daily inspections of the stools : — 

Whole milk 6 oz. 

Diluent 14 oz. 

Sugar I oz. 

Salt I pinch. 

Whole milk 7 oz. 

Diluent 13 oz. 

Sugar I oz. 

Salt I pinch. 



80 ARTIFICIAL FEEDING. 

Whole milk 8 oz. 

Diluent 12 oz. 

Sugar I oz. 

Salt I pinch. 

And so on, the guide to change from one strength to a 
higher concentration meanwhile being a cessation in the 
continuous weekly gain, as previously stated. 

Weighing should never be practised oftener than twice 
weekly, and preferably but once weekly, for the reason 
that too frequent weighing causes discontent, disturbs the 
mother, and is likely to warp the physician's good judgment, 
thereby causing him to make changes in the food too 
frequeaitly. 

Thus this method of increasing the strength and then 
the size of the meal is persistently pursued toward the end, 
until the infant receives whole undiluted cows' milk. This 
is the goal. "When is this reached?" is a pertinent ques- 
tion. Not meaning to give an asinine answer, the best 
reply in my experience is that it is reached "when it is." 
The idea intended to be implied is that there can be no 
definite age limit. The digestive capabilities of the in- 
dividual can alone determine this point. It may be at 6 
months, slightly before, or not until 9 months or i year. 
The individual's digestive capacity can only be determined 
by cautiously proceeding according tO' the method indicated, 
of replacing an ounce of diluent by an ounce of milk and 
then slightly increasing the size of the meal and watching 
the effect. If this be for good, advance is made by employ- 
ing the next stronger formula. If it disturbs the digestion 
we return again to the formula immediately preceding, or to 
a still weaker one, or we may adopt one or another of the 
maneuvers described in fat, sugar, or protein intolerance, as 
the case may be. 



4 



PLATE VII 




Hard, constipated, calciiim-soap stool. Commonly seen where too 
much fat is administered in the formula. The fatt}' acids combine with 
the mineral substances contained in the intestinal mucus, which is in- 
creased as a result of the irritating effect of these acids. For this 
reason the passage of this constipated movement may be accompanied 
or followed by loose material. These babies either remain stationary 
or lose in weight, and often have an ammoniacal urine. For treatment, 
see text on fat intolerance. This stool is also of good prognostic sig- 
nificance in cases of diarrhea which have been placed upon buttermilk 
or eiweissmilch, the calcium casein of these preparations combining 
with the fatty acids, producing the caseate of lime or calcium-soap 
stool. When this is secured a return may be made to diluted-milk 
formulas. 



METHODS OF MILK ADAPTATION. 81 

If at any time during the course of a feeding case it is 
deemed necessary to determine the percentage strength of 
the formula which the infant is receiving, or to note its 
caloric value, this can readily be accomplished roughly 
with reference to the percentage of fat, sugar, and protein 
by regarding cows' milk as a "four, four, four mixture," 
that is, F. 4 per cent., L. 4 per cent., P. 4 per cent. 

Example: — 
Milk 5 oz. 

Diluent 15 oz. 

Sugar I oz. 

Fat = %o = M. M of 4% = I %. 

Therefore, since each ingredient equaled 4^, we would 
have F. 1%, L. 1%, P. i^. Toi this however i ounce of 
sugar has been added; therefore, as i ounce in 20 equals 
V20 or 5% extra carbohydrate, this is added to the 1% 
obtained originally fro-m the milk. Consequently, the total 
carbohydrate equals 1% plus 5%, or 6%. The final for- 
mula consequently would read : — 

F. 1%, L. 6%, P. 1%. 

Rule to Determine the Percentage Strength of any 
Formula of Diluted Whole Milk. — Divide the number of 
ounces of whole milk used by the number representing in 
ounces the total bulk of the mixture. Multiply the result- 
ing fraction by 4. To the result obtained with reference to 
the sugar add the result secured by dividing the number 
of ounces of additional sugar by the number representing 
in ounces the total bulk of the formula, and multiply this 
by 100. Add this number to the number obtained with ref- 
erence to the sugar percentage. 

The caloric value of the mixture is readily determined 
by multiplying each ounce of milk by 21 and each ounce of 



82 ARTIFICIAL FEEDING. 

sugar by 120 and by adding these together. Of course if 
the mixture totals 40 oz. and if in twenty-four hours the 
child receives, say, but 30 oz. of this, then the total num- 
ber Oif calories actually received by the child in twenty-four 
hours represents ^^/^o 01* H of the total number of calories 
represented by the entire form,ula. (See next page.) 

It will be noticed that all of the formulae preceding are 
calculated in total amounts of 20 ounces. This has been 
adopted merely as a matter of convenience and of habit. 
If the total daily quantity of formula equals 25, 30, 35, or 
40 ounces, then each ingredient in the 20-ounce formula 
must be multiplied by 1.25, 1.50, 1.75, or 2 as the case 
may be. 

The sugar which is added is, for practical purposes, dis- 
regarded as far as its influence upon increasing the total 
volume of the formula is concerned. It must be further 
stated that, as the concentration of the formula increases and 
approaches the strength of ^4 niilk and. %. diluent, the sugar 
is gradually decreased by % ounce amounts in the 20- 
ounce mixture until it is finally omitted. 

Calory Feeding. — This is a method of feeding based on 
the caloric requirements of the infant as determined by its 
weight. An infant up tO' 6 months needs approximately 
about 100 calories per kilogram of body weight, or about 
45 calories per pound. As the child approaches a year the 
caloric requirement is somewhat less — between 85 and 80 
calories per kilo', or 32 to 35 per pound. ^ These figures 

1 The exact figures given by Heubner and Rubner are as fol- 
lows: — 

First 3 months 100 calories. 

Second 3 months 90 calories. 

Third 3 months 80 calories. 

Fourth 3 months 70 calories. 



I 



METHODS OF MILK ADAPTATION. 83 

have reference to healthy infants. Some undernourished 
or premature habies require as high as 125 to 175 calories. 
One quart of cows' milk equals 680 calories. One quart of 
human milk equals 615 calories. Allen has concluded that, 
in order tO' maintain nitrogen equilibrium, it is necessary 
for the infant tO' receive the protein contained in i ounce 
of co'ws' milk for every pound of body weight. There- 
fore if it be desired tO' provide f<3T body growth and 
development in addition, it is necessary to give from; lYz 
to 2 ounces of cows' milk for every pound of weight. 
Hence, tO' determine how much milk is tO' be employed in 
the fonnula, the weight is multiplied by i^ or 2. This 
result is deducted from the total quantity of food required 
in twenty-four hours in order tO' leam the amount oi 
diluent necessary. Any deficiency of caloric value is made 
up by adding carbohydrate in the form of lactose, saccharose, 
or maltose, preferably the last two'. One oiuice of all 
sugars by weight about equals 120 calories. One ounce of 
4 per cent, milk approximates 21 calories. 

Example. — A healthy infant 6 months old weighs 15 
pounds and is receiving 7 ounces of food six times a day. 
Total quantity in twenty-four hours equals 6 multiplied by 
7, or 42 ounces. 

15 ^ 45^=675 calories required in twenty-four hours. 
15 X 1.5:= 22.5 oz. milk. 
42 — 22.5 = 19.5 oz. of diluent. 
22.5 X 21 = 472.5 calories provided by the milk. 
675 — 472.5 = 202.5 calories, which can be supplied approximately 
by 1.75 oz. of sugar = 210 calories. 

The infant therefore receives 472.5 + 210 = 682.5 
calories. 

Advantages of This Method. — Its simplicity at once 
appeals. All that is necessary is to multiply the infant's 



84 ARTIFICIAL FEEDING. 

weight by 1.5. Add sufficient diluent to bring up the bulk 
of the food toi the twenty-four-hour requirement and suffi- 
cient carbohydrate to raise the caloric value to the weight 
requirement. As a check upon percentage feeding it is 
valuable in that it permits the physician to- know whether 
he is feeding under or above the food tolerance for the 
individual. 

Disadvantages of This Method. — It does not take into 
consideration the strength of the food. Thus an infant of 
3 months weighing 7 pounds would receive a much weaker 
mixture — as the total amount of food would be greater — 
than an infant of I week weighing 7 pounds. In the latter 
instance the strength of the food would probably be too 
great, as the total daily bulk would be less, and therefore 
the milk would not be sufficiently diluted. 

Caloric feeding completely ignores the digestive capacity 
of the individual baby, taking cognizance alone Oif the heat 
units required. Further, in oirder to^ receive the number of 
calories necessary, the entire amount of the milk mixture 
provided for twenty-four hours must theoretically be con- 
sumed within that space of time. As a practical proposition 
this is often impossible, due to the vagaries of the infant's 
appetite as well as to other unpreventable causes. 

Experience seems to show that in order to make the 
baby gain in weight it is necessary tO' provide more calories 
than 45 per pound of body weight. Often one and one- 
half and even twice this number must be given. If one 
adopts calory feeding as his method of nourishing infants, 
he may become as dogmatic in his statements as one who 
adheres entirely to- percentage feeding. In order to be suc- 
cessful it is necessary to' individualize as in any other 
method. 



METHODS OF MILK ADAPTATION. 85 

In ordering a milk mixture, whether percentage or 
calory, the fo'llowing form has proved to be useful when 
handed to the child's caretaker. 



Name Date 

Weight Age 

Fat per cent. Sugar per cent. 

Protein per cent. Daily Amount 

(Make fresh daily.) 
Calories required 

Milk oz. 

Skimmed milk oz. 

Cream oz. 

Whey oz. 

Barley-water oz. 

Oatmeal-water oz. 

Boiled water oz. 

Rice-water oz. 

Lime-water oz. 

Sugar oz. 

Salt. 

C Soda cit 

Medicine -| Saccharin 

( Other 

Pancreatized minutes. 

Feed oz. every hours, giving oz. 

in twenty- four hours. 

Diluents. — Of the diluents employed with cOws' milk, 
water probably enjoys the largest field of usefulness. 
Aside from its diluting properties, it is a valuable thera- 
peutic agent when used intelligently. It is essentially a food 
and is necessary for the digestion and assimilation of all 
other foods. Without it the physiologic activity of the 
economy would cease. It not only allays thirst, but in 
physiologic quantities, adniinistered regularly, it increases 
the flow of gastric juice. It renders soluble the salts of the 
gastric contents and prepares them for absorption. By in- 
creasing the fluidity of the intestinal contents it acts as a 
laxative and prevents constipation. It dissolves and dilutes 



86 ARTIFICIAL FEEDING. 

toxins, favoring their elimination through the skin and kid- 
neys. It maintains blood-pressure. It forms the main 
component part of every secretion and excretion of the 
body. It favors the deposition of fat. 

As a diluent therefore in milk mixtures it forms an 
invaluable addition as a nutritive agent. While its action 
is to dilute all the ingredients of the milk, it does not, to any 
considerable extent, change their physical characters. The 
curd formed by rennin with milk, diluted with water, is 
almost as tough and dense as that obtained with undiluted 
cows' milk. 

To overcome this Jacobi, many years agO', first 
devised the use of cereal decoctions, for wbich he claimied 
the power of mechanically dividing the tough curd of cows' 
milk intO' a fine, flocculent, porous curd. For this purpose 
he recommended the use of barley-, wheat-, oatmeal-, and 
rice- water. Barley-, wheat-, and rice- water are toi be 
employed when diarrhea exists, and oatmeal-water is added 
as a diluent with constipated children. 

Dextrinized gruels are advocated as a diluent, especially 
by H. D. Chapin and Keller. They gO' a stepi farther in 
the use of plain cereal decoctions. Instead of using the 
plain cereal-water or thin gruel, they submit the latter to 
the action of some diastatic agent, the:reby changing the 
starch to dextrin. 

The efficacy of dextrinized gruel, made from' wheat- 
flour^ has been tested in a number of feeding cases, in the 
Medico-Chirurgical and in the Philadelphia General Hos- 
pitals. It was added toi the milk mixture, as a diluent, 
in the same amount as the formula called for water, the 
gruel taking the place of water. The first case did remark- 
ably well, the child gaining in weight on an average of i J4 



METPIODS OF MILK ADAPTATION. S7 

ounces a day, curds disappearing from the stools, which 
became normal in appearance. Other children, all infants 
under i year of age, showed varying results. Some grew 
fat and strong, others showing no change either in weight 
or in the character of their stools. In the test-tube the 
addition oi dextrinized gruel certainly causes the milk to 
coagulate in fine, feathery, flocculent curds, when acted upon 
by rennin. In the stomach of some infants the effect is 
decidedly different. One case of miliary tuberculosis, which 
came to autopsy, showed a large, dense, tough curd in the 
stomach after having been fed four hours before death with 
a mixture which contained only 0.25 per cent, of protein. 
This may have been due to insufficient gastric motor power 
or to large doses of subgallate of bismuth which was ad- 
ministered to control intestinal hemo'rrhage. Koplik has 
made use of dextrinized gruels in about 50 cases of subacute 
and chronic enteric catarrh associated with marasmus. He 
believes this method of feeding to be of service in older 
children who refuse milk. He quotes Keller's experience 
as finding the amount of ammonia in the urine diminishing 
in marantic infants who suffer from an acid intoxication 
of the gut. 

Barley-water. — Scald one tablespoonful of white pearl 
barley and throw away the water. One quart of water is 
then poured over the barley. It is allowed tO' boil down to 
one pint and is strained. Barley-water is useful for a short 
time in the treatment of the summer diarrheas as a substi- 
tute for milk. It contains a small amount of nourishment 
and is constipating. It is a useful vehicle for the adminis- 
tration of stimulants. It is also added to milk as a sub- 
stitute for water to attenuate the curds in the presence of 
protein indigestion. 



88 ARTIFICIAL FEEDING. 

Barley-gruel or Barley- jelly. — Two to three ounces oif 
barley-flour, either Robinson's or that prepared by the Cereo' 
Company of Tappan, N. Y., are rubbed into a smooth paste 
with water and then sufficient water added to make one pint. 
Boil with constant stirring for twenty minutes, add suffi- 
cient hot water to make up for the amount evaporated, salt 
to taste. When cool the substance sets into a thick jelly. 
In making the gruel a little less barley-flour is used. 

Oatmeal-water. — This is of service in the attenuation of 
the curd of cows' milk when used as a diluent in place of 
plain water, especially in the presence of constipation. Add 
one tablespoonful of oatmeal tO' one pint of boiling water. 
Simmer for thirty tO' sixty minutes. The bulk is again 
brought up tO' a pint by the addition of boiling water. 
Strain. Salt tO' taste. 

Oatmeal-gruel or Jelly. — This may be made either from 
the plain oatmeal or from CereO' oat-flour. In the latter 
instance the preparation is similar to barley-gruel or barley- 
jelly. In the former three tO' four ounces of oatmeal are 
added to one pint of water. Boil for three hours, prefer- 
ably in a double boiler. Water is added in the mean time to 
make up for evaporation. Strain. Salt to taste. When 
cool it jellies. It may be fed in this way or added tO' milk 
in varying amounts to attenuate the curd. 

Wheat-flour Water. — This may be used as a diluent of 
milk in the presence of diarrhea. One to twO' teaspoonfuls 
of wheat-flour are added without lumping to one pint of 
water. Boil thirty minutes. Stir constantly. Add suffi- 
cient water to a pint. Strain. Salt to taste. 

Arrowroot-water.— Rub one teaspoonful of arrowroot 
into a smooth paste with a little cold water. Add tO' one 
pint of hot water. Boil five minutes with constant stirring. 



METHODS OF MILK ADAPTATION. g9 

Rice-water. — This is used as a milk diluent in cases of 
diarrhea, or may be given plain tO' the infant. One table- 
spoonful of clean rice is coivered with a quart of warm water 
and permitted to stand for one hour. Boil until the volume 
is reduced to one pint. Strain. Salt to taste. 

Dextrinized Gruels. — Dextrinized gruels are made either 
froim wheat-, barley-, oatmeal-, or rice- flour in the follow- 
ing manner: One toi two tablespoonfuls of any of these 
flours is stirred into a thin, smooth paste with a little water. 
This is added to one pint and a half of water and boiled for 
fifteen or twenty minutes with' constant stirring, using a 
long-handled spoon. The gruel is then removed irom the 
fire and allowed to cool. When cool, enough tO' taste, one 
teaspoonful of a preparation of diastase is added and mixed 
well with it. Upon the addition of diastase the gruel at 
once becomes thin and watery; 51 to 10 grains of taka- 
diastase may be dissolved in a teaspoonful of water. Use 
may be made of any preparation of malt, as Liebig's malt 
extract or of Cereo^, which is a glycerite of diastase. 

Malt Soup. — In 1898 Keller published reports of his 
experiments at the University Childrens' Clinic in Breslau. 
The preparation of choice is Loeflund's malt sonp. It is 
a thick, syrupy substance of brownish color and pleasant 
odor. It contains potassium carbonate, the purpose of 
which is to overcome the acidity of the malt. It is employed 
as follows : From, i to 2 ounces of malt soup are added to 
I pint of warm water (solution No. i). From i tO' 3 
ounces by measure of wheat-flour are smoothly mixed with 
I pint of milk and strained (solution No. 2). The two 
solutions are mixed and slowly brought tO' a boil with con- 
stant stirring. Cool and bottle. The amount of malt soup 
and flour may be varied as indicated. If diarrhea or vomit- 



90 ARTIFICIAL FEEDING. 

ing occur, less malt is employed; if abdominal distention, 
less flom-. On the other hand, the proportions of milk and 
water may be adjusted toi suit any desired percentages. 
The effect of mixing these solutions is to provide a dex- 
trinized cereal — dextrin and maltose. 

Milk prepared in this way has undoubtedly a large field 
of usefulness in marantic infants whose digestive organiza- 
tion is SO' delicate that it is next tO' impossible tO' secure a 
food that will agree or produce a gain in weight. Cases of 
essential marasmus often gain with tremendous strides when 
placed upon this food. Cases which have difficulty in 
digesting the' curd, but show' a. tolerance for starch, are 
benefited, while those that vomit and have diarrhea do not 
thrive upon this food. The addition of malt soup should 
not be permanent, but is only tO' be employed for the pur- 
poses indicated — especially protein indigestion — and grad- 
ually discontinued when the bowels are normal or the 
weight ceases to increase. It is especially useful in cases 
which show acidosis as the ammoniumi output is decidedly 
lessened. 

Alkalies. — Although, as stated, by the time that cows' 
milk reaches the consumer it is slightly acid, alkalies are 
not to be employed routinely, but for a; distinct indication. 
This indication is to overcome hyperacidity, to assist in pro- 
tein indigestion, and to overcome the effects of acidosis 
attendant upon toO' much fat in the food, as indicated by an 
ammoniacal urine. Of alkalies lime-water is the most com- 
monly employed in the amount of from. 5 per cent, (com- 
mon) to as much as 20 tO' 30 per cent, of the milk mixture. 
Besides overcoming acidity, it causes the curd to become 
attenuated and improves the flavor of the milk. 



J 



METHODS OF MILK ADAPTATION. 91 

Sodium citrate finds its greatest advocates in Wright 
and Poynton, of England, and Vaderslice and Cotton, of 
Chicago. It is added to milk in the strength of from i to 3 
grains for every ounce oi milk and cream in the mixture. 
It prevents, if in sufficient strength, coagulation of the milk 
in the stomach, thereby entirely eliminating gastric diges- 
tion. As can readily be appreciated, this is not desirable 
as a routine measure, weak digestion would be an 
indication, especially where the motor function is impaired 
or in cases of pyloric obstruction. The addition of sodium 
citrate, gr. 10 tO' gr. 30, before each feeding, either in 
the breast- or bottle- fed, is a valuable means of seeking to 
allay vomiting by permitting the milk tO' pass more readily 
into the duodenum on account of its unclotted condition. 
The exact manner of the action of sodium citrate is un- 
known. It is assumed that the citric acid liberated combines 
with the lime-salts of the milk, forming citrate of calcium. 
The calcium being thus bound, the free sodium unites with 
the free casein to form sodium paracasein, which, in con- 
tradistinction tO' the curd, calcium paracasein, is in solution. 

Sodium bicarbonate is not commonly employed, but is 
indicated in hyperacidity, and is used in the strength of 
from I to 5 grains' for every ounce of milk and cream, in 
the mixture. 

Pasteurized Milk. — This means the process by which the 
milk is subjected to a temperature of 155° F. for a period 
of about thirty minutes to an hour, after which it is rapidly 
cooled to 68° F. The best means of pasteurizing is by the 
Freeman instrument (Fig. 17). This consists of a metal 
bucket or pail which has a removable lid (A) and a groove 
encircling it about one-third from the bottom. In this 
bucket fits a metal rack (B), which is made to hold bottles 



92 



ARTIFICIAL FEEDING. 



(C). Twoi sizes are made: one Iwlding lo bottles, the 
capacity of which is 6 oz., and one holding 7 bottles, the 
capacity of which is 8 oz. The rack has a wire crosspiece 
{D) by means of which it can be raised when the cross- 
piece is made to rest on a metal support (£) which projects 
into the bucket. 




Fig. 17. — Freeman's pasteurizer. A, cover; B, metal rack; C, bot- 
tles; D, crosspiece; E, support; F, separate compartments. (Physi- 
cian's Supply Co., Phila., Pa.) 



The pasteurizer is filled tO' the groove with water and 
placed over a hot fire. When the water boils, each bottle, 
after being sterilized and having been filled with the desired 
quantity of milk mixture, is stoppered with sterile cotton 
and placed in its own compartment {F) in the metal bracket, 
and cold water is allowed tO' run into each compartmicnt. 
Any compartments that do not contain miilk formulas are 
occupied by bottles filled with water. The rack is then 
placed in the pail containing the boiling water. The lid of 
the pasteurizer is now adjusted and the apparatus is taken 



METHODS OF MILK ADAPTATION. §3 

from the fire. It is left undisturbed for from/ thirty minutes 
to one hour, when it is carried under a faucet of cold water, 
the lid remoA'ed, and the rack raised so the crosspiece (D) 
rests on the metal support (E) which projects into the 
bucket, and cold water is permitted to^ run intO' the pail, 
thus rapidly displacing the hot water. The bottles are now 
removed from the rack, stoppered with sterile cork stop- 
pers, and placed on ice. Before feeding they are slightly 
warmed by being placed in warm water. 

While it is true pasteurization does not make a dirty 
milk clean nor a fit food for infants, it is the best and safest 
procedure we at present possess. It is, perhaps, a good 
rule to pasteurize all milk, even when the method' of its 
production is known to> be the best, during four months of 
the year (June, July, August, and September). Some 
dealers sell pasteurized milk. This is a delusion and a 
snare, as it has been clearly shown that pasteurized milk is 
a better culture medium than raw milk. Hence the home 
product is best, as it is not kept sufficiently long toi be 
expoised tO' contamination. 

A rough method of pasteurization applicable to cases 
wherein expense is a desideratum, that is efficient, is to place 
the milk or formula into a sterilized Mason jar. The latter 
is then placed into a vessel containing cold water which 
reaches at least two-thirds up the sides of the jar. The 
water is brought tO' the boil, at which time it is removed 
from the fire, the lid placed upon the Mason jar, and the 
whole allowed gradually tO' cool off. The formula is now 
bottled. In summer this method is better than none at all, 
and is decidedly superior to sterilization, since the tempera- 
ture of the milk, while rising higher than when using the 
Freeman apparatus, is considerably less than the boiling 



94 ARTIFICIAL FEEDING. 

point, — a fact of much importance if the process is tO' be 
continued over a long period of time. 

Sterilization. — By steriHzation is meant the destruction 
of germs by boihng. It may or may not include the 
destruction of the bacterial toxins. This depends upon the 
character of the toxin and its power tO' resist a temperature 
of 212° F. Boiling is usually continued for fifteen to 
twenty minutes. It is a fact that this milk can be kept for 
many months. It is further a fact, well established beyond 
dispute, that such milk fed to infants, over a long period 
of time, will produce scurvy and perhaps rickets. This is 
due to the chemical changes which occur in the milk. The 
boiling temperature coagulates the lactalbumin which rises 
to the surface, entangling the fat. It forms the so-called 
"skin" of boiled milk. Sterilized milk should not be fed to 
infants ordinarily. However, in some cases it miay be the 
choice between two evils as a temporary measure. Thus, in 
the summer months, it may be the safer plan to tell the slum 
mother to boil her milk before feeding it tO' her infant, than 
toi assumie the risk of a severe intestinal infection. It is 
further borne out by clinical experience that boiling the 
milk for a short period (five minutes) greatly assists^ in 
rendering the curd digestible. 

Pancreatized Milk or Pancreatized Formula. — This is 
sometimes poorly named peptonized milk. .Predigested 
milk, which is synonymous, is a better term than the latter. 
Dissolve the contents of one of Fairchild's peptonizing tubes 
in I ounce of water. Add this to a pint of the completed 
formula. Mix. Place the vessel containing this in water 
of 115° F. for as many minutes as directed tO' do so. At 
the end of the required time, either divide intO' the number 
of needed bottles and place at once on ice, or bring the 



METHODS OF MILK ADAPTATION. 



/ 

95 



mixture to a sudden boil. Either method will stop the pan- 
creatization. If the formula or milk becomes bitter, the 
process has been carried too' far. 

Uses. — Pancreatized milk is useful in cases of indiges- 
tion where the baby cannot digest the curd or fat of the 
milk. It does well in some cases of essential marasmu;S. 



I^ffi 


^B^v 




V 


K 


1 




"^.y^^l 


^Iv-oi^ 


1 




f^M 


^bb 


iS 




1^ 



Fig. i8. — Apparatus used in mixing formula. Pitcher, i6-oz. glass 
graduate, sugar measure, large spoon, nursing bottle, glass or agate 
funnel, corks. (Physician's Supply Co., Phila, Pa.) 

The combination of i teaspooniful of pulverized flour ball 
to each bottle of pancreatized formula often forms a useful 
addition in curd dyspepsia. 

How to Prepare Formula. — The preparation of the for- 
mula in the home must be done with care, especially with 
regard tO' cleanliness. This bears reference not only tO' the 
proper icing of the milk, but to everything else, including 
the hands of the nurse or mother, all utensils, water or 



96 ARTIFICIAL FEEDING. 

diluents, bottles and nipples that may come in intimate con- 
tact with the milk. The number of ounces of milk or 
skimiiied milk required are placed in a large sterile pitcher 
miade of glass or agate (Fig. i8). Into this is measured, 
by means of a i6-'0unce glass graduate, the required 
amount of diluent. To this is added the sugar, salt, or any 
other solid ingredient required. A druggist will furnish 
a small receptacle or box marked to measure an ounce of 





Fig. 19. — Nursing bottle. Fig. 20. — A good type of nipple. 

sugar by weight. The whole is thoroughly mixed with 
a large sterile spoon. It is now placed in bottles by 
means of a glass, agate, or tin funnel, previously steril- 
ized. The bottles are preferably stoppered with sterile 
corks. If no. further manipulation is required, the bottles 
are well iced after cooling, and placed preferably in a special 
nursery refrigerator (Fig. 23). Under no circumstances 
are they permitted toi come in contact with food. If it be 
necessary tO' pasteurize, while in the pasteurizer the bottles 
must be closed with cotton which is later replaced by corks. 
Hygiene of the Bottle and Nipple.— The successful feed- 
ing of artificially reared infants, aside from the chemical 



METHODS OF MILK ADAPTATION. 97' 

composition of the milk mixture, necessitates the strictest 
attention to details. Of these the selection and care of the 
nursing" bottle and nipple are matters of importance. Gen- 
erally speaking, that bottle and nipple are the best which are 
simplest in construction and are the most easily cleansed. 
Bottles with many curves and angles are harmful. The 
use of nursing" bottles with long rubber tubes is an abomina- 
tion and should be prohibited by law. They are germ car- 
riers, cannot be cleansed, and favor decomposition of the 
milk. The best bottle is one holding about 6 or 8 ounces, 
and which consists essentially of a graduated straight tube. 




Fig. 21. — Bottle-brush. (Physician's Supply Co., of Phila.) 

tapering slightly as it reaches the top (Fig. 19). The 
bottle should be thoroughly cleansed with Castile soap and 
hot water, using a stiff brush (Fig. 21) on a long handle. 
It is then thoroughly rinsed with plain, boiling water and 
filled with sterile borax-water when not in use. Before 
using, it is again thoroughly scalded. The brush used to 
clean the bottle must also be sterile. 

The best nipples are those which allow the milk to flow 
easily but not too rapidly. When the feeding bottle is in- 
verted, the milk should drop from the nipple and not run 
from it (Fig. 22). Nipples which permit the milk to flow 
rapidly produce colic. Those which flow too slowly may 
vex and irritate the infant. One of the best nipples is known 
as the Mizpah. The Davidson Health nipple is also a good 



98 ARTIFICIAL FEEDING. 

one (Fig. 20). Any nipplel which is simple in construction 
and easily cleansed may be recomm,ended. The nipples made 
from red rubber contain lead, therefore only the black- 




Fig. 22. — Showing correct rapidity of flow of 
formula through nipple. 

rubber ones are to be employed. A nipple should not be 
used longer than a week, as the rubber becomes poor and is 
not easily sterilized. The same treatment should be 
accorded the nipples as the bottles, except that they should 



METHODS OF MILK ADAPTATION. 



99 



not be boiled. They are turned inside out and well 
scrubbed with Castile soap and hot water. Afterward they 
are rinsed in hot, sterile water. When not in use they are 
kept in a solution of sterile borax-water or boric acid solu- 
tion. Immediately before use they are immersed in sterile 
water. Blind nipples are purchaseable and are convenient 




Fig. 23. — Nursery refrigerator. (Courtesy of Gimbel 
Bros., Phila.) 



when it is impossible to secure nipples with sufficiently 
small holes. The latter are made by passing" a fine, red-hot 
needle through the apex of the nipple. A great incon- 
venience, difficult to overcome, is the collapse of the nipple 
while the infant is sucking. In order to obviate this, a 
nipple and bottle called the Novae have been placed on the 
market and are of some value. 

Diet-kitchen; Refrigerator. — If available, a small room 
especially set aside as a diet-kitchen, devoted entirely to 



100 ARTIFICIAL FEEDING. 

the preparation oi the infant's food, is desirable. In hos- 
pitals this is essential. Among the poor, however, the 
physician, if he will but interest himself, can do much to 
improve the hygienic surroundings, so that the preparation 
of the food may be accomplished with safety. Ice is essen- 
tial to the preservation of the formula. A very convenient 
and hygienic arrangement is the nursery refrigerator, to 
which reference has already been made (Fig. 23). These 
refrigerators come in two sizes and may be purchased for 
from $1.50 to $3.00. The sides are packed with mineral 
wool. They are divided into two compartments, one in 
which the bottles may be kept surrounded with ice and 
another in which such things as the milk, barley-water, and 
beef -juice may be kept. Icing the milk or formula is a 
serious problem with the poor and ignorant, especially 
during hot weather. Very often a bottle half-finished will 
be permitted to lie around for several hours, to be again 
offered to the infant. This practice is exceedingly danger- 
ous and must be prevented. 

How to Tell when Formula Agrees. — The best evidence 
that the proper food has been selected for the infant is fur- 
nished by the condition of its digestion and its weekly 
weight record. The stools may not at once become normal. 
The change is usually gradual. Too frequent alterations 
in the composition of the food are not tO' be made. The 
individual digestive apparatus must be given an opportunity 
to become accustomed to the new food. This only applies 
to niinoir disturbances. Severe gastrointestinal derange- 
ments call for radical changes. A gain of from, 5' to 7 
ounces a week is normal. Less than this, in the beginning 
of the use of a new food, until* the proper strength is reached 
is satisfactory. The infant's disposition while awake, and 



/ 

METHODS OF MILK ADAPTATION. >lt)l 

its ability tO' secure a proper amount of sleep, are first-hand 
•guides as to the success of the feeding, unless the baby be 
hampered and viciously trained. 

Feeding Routine ; Amounts to be Fed ; Feeding Interval ; 
Diurnal Feeding; Nocturnal Feeding. — No fixed rule can or 
should be given. The demands of the individual must be 
met. As the student requires some guide upon which to 
base his original advice v^hich may be adjusted by future 
observation, the following, as representing the result: oi 
practical experience, is suggested. Up to 6 months the 
number of ounces of each feeding may approximately he 
represent el by the infant's age expressed in months. After 
this the progression is somezvhat slower, so\ that at i year 
it receives abottt lo ounces. 

The feeding interval should be every two hours until 
after 3 months, with two night feedings after midnight. 
The infant is tO' be awakened regularly for its meals during 
the day on the exact feeding hour, timing from' the com- 
mencement of the last meal and not from the finish. Be- 
fore feeding, the food is to be properly warmed by im- 
meirsing the bottle in hot water. The formula will be of the 
proper temperature when it can be comfortably dropped 
upon the back of the hand. The bottle must be held for 
very yoimg infants. The infant is not permitted tO' suck 
air. The neck of the bottle is always kept full. The infant 
may not sleep with the nipple in its mouth. The meal 
should be finished within from fifteen to^ twenty-five 
minutes. The food must not be given too rapidly. This 
may be guarded against by having a nipple which does not 
permit too rapid a flow, and by removing the nipple fro'm 
the infant's mouth at the end of every third or fourth suck. 
The meal should be given with the infant lying down. 



102 



ARTIFICIAL FEEDING. 



After feeding, its mo'Uth is gently cleansed! with boric acid 
solution and the infant must not be picked up. From' the 
third tO' the end of the sixth month the feeding interval is 
lengthened to two and one-half hours ; from the seventh to 
the end of the ninth mionth, every three hours; froim' this 
time toi 12 months, every three and one-half hours. 

After the fourth month, and sooner if feasible, no night 
feedings are tO' be given unless under exceptional circum- 
stances. (See Vomiting, Chapter VII.) The adoption of 
some such routine has an excellent effect upon the patient's 
nerA'OUS development and its digestion. Good feeding 
habits are as easy to inculcate as vicious ones, and make 
for the comfort of the infant and the general good morale 
of the entire household. The infant should, if possible, be 
in a room by itself and left immediately as soon as its meal 
is finished and its general wants attended. Soon it will be 
found that the baby will respond tO' this scheme of regularity. 
It may take a week or more to accustom some infants tO' it, 
but the trial is worth the effort on account of the future 
comfort which ensues. 

Feeding Table. 



Age. 


Amounts to 


Feeding 


Daily 


Night 


be fed. 




interval. 


quantity. 


feedings. 


Up to 3 weeks 


I to 2 


oz. 


2 hours 


II to 22 oz. 


2 


Up to 2d month 


2.y2 td 3 


oz. 


2 hours 


25 to zz oz. 


2 


Up to end of 3d m. 


3 to 3^/^ 


oz. 


2 hours 


25 to 35 oz. 


I 


During 4th month 


4 to 5 


oz. 


2^ hours 


32 to 40 oz. 


I 


During 5th month 


5 to 6 


oz. 


2^ hours 


35 to 42 oz. 





Up to end of 6th m. 


6 to 7 


oz. 


2^2. hours 


42 to 45 oz. 





During 7th month 


7 to 8 


oz. 


3 hours 


42 to 48 oz. 





During 8th month 


7 to 8 


oz. 


3 hours 


42 to 48 oz. 





Up to end of 9th m. 


8 to 9 


oz. 


3 hours 


45 to 50 oz. 





During loth month 


9 


oz. 


3>^ hours 


45 to 50 oz. 





During nth month 


9 


oz. 


3^ hours 


50 to 55 oz. 





Uptoendof I2thm. 


10 


oz. 


3^ hours 


50 to 55 oz. 






METHODS OF MILK ADAPTATION. 103 

Individual peculiarities or digestive disturbances may 
necessitate a radical change in the feeding routine as to 
feeding interval 2ind quantity to be fed. No absolute routine 
may be prescribed for all babies. Here as elsewhere in- 
dividualization must be the basic keynote of practice. Thus 
the advocates of a regular four-hour interval may be as 
dogmatic as they desire to be regarded as progressive. 
Reference to the indications for shorter or longer intervals 
and for larger or smaller amounts to be fed will be found 
in their proper place within the body of the text. 

Bottle Feeding Among the Poor. Milk Stations. — 
Among the poor, the artificial feeding of infants who are 
deprived of breast milk, is a problem' that touches the ques- 
tion of infant mortality and concerns the State as well as 
the individual. Economic conditions underlie the entire sit- 
uatioin. The conservation of the human milk-supply is vital, 
and it does not seem tO' be Utopian to express the hope 
that the nursing mother of the poor may some day become 
the ward of the State during the lactating period, or be paid 
outright for her services in nursing an infant so that she 
may be relieved of all other material responsibility during 
this time. 

Where the infant is artificially reared, accurate adjust- 
ment to the individual's digestive peculiarities is just as 
possible, with somic exceptions, if the physician takes the 
trouble to teach the mother, as among the better classes. 
The greatest difiiculty is, however, to secure pure milk at a 
reasonable price and to keep the formula properly iced until 
used. Good milk cannot be secured if purchased fro^m cans 
in the open market. For this reason milk stations have been 
established to provide it at cost or, in worthy cases, free. 
These milk stations, in conjunction with the visitinj 



104 ARTIFICIAL FEEDING. 

have accomplished much in the reduction of infant mortahty. 
It appears, however, to be a useless expenditure of funds 
where much more good could be done by sustaining the 
mother during the nursing period, as previously stated. 
Pasteurization if feasible and, if not, sterilization should be 
practised during the summer months. The latter is easier 
and more certain, and should always be advised without 
thought as tO' the future development of scurvy. This may 
be combated by the simultaneous administration of fruit- 
juices. 

Condensed milk, being sterile, is a valuable makeshift 
when added to boiled water, and may be successfully used 
in many instances throughout the summer months. 

Feeding while Travelling. — If the journey be short, occu- 
pying twenty-four hours or less, a day's supply of a formula 
may be prepared and placed in a sterilized Thermos bottle, 
or be bottled and put into^ a small receptacle, as a bucket, and 
properly iced. Where a journey of some distance is to be 
taken, as a sea-voyage, reliance may confidently be placed 
upon condensed milk or Ramogen. 

THE DIGESTIVE DISTURBANCES OF THE BOTTLE-FED 
AND HOW TO TREAT THEM. 

Pediatrists are agreed as to the frequency of the diges- 
tive disturbances of the artificially reared, as well as to the 
serious and often fatal effects these may have upon the 
nutrition of the infant. Difference of opinion, however, 
exists as tO' the etiologic basis of these digestive upsets. 
The controversy as to which of the food elements, fats, pro- 
tein, or sugar, of cowls' milk, is responsible still continues, 
although the German contention, that most of the trouble 
depends upon a relative excess (for the individual) of fats 



ATE VTTT 




Hard, dry, whitish, constipated, crumbly stool, consistino- of undi- 
gested protein, occurring in a bottle-fed baby. These movements are 
passed with much straining". (See text for treatment of protein intol- 
erance.) 



[ 



DIGESTIVE DISTURBANCES OF BOTTLE-FED. 105' 

and sugar, and rarely upon a relative excess of protein, 
seems tO' possess at the present time the predominant influ- 
ence upon the medical mind. An active feeding experience 
of fifteen years does not permit entire accord with this 
view. It is patent that the feeding of an excessive relative 
amount of any or all of the food elements may cause trouble, 
but the attempt to harness the responsibility upon one or 
more to the exclusion of the rest appears dogmatic and futile. 
The researches of von Pirquet clearly demonstrate that the 
infant thrives best when fed the food optimum (an amount 
just within the limit of the greatest quantity of food that the 
organism can assimilate, i.e., the limit of food tolerance), 
and that loss of weight results from exceeding the food 
maximum as quickly as when the infant receives less than 
the minimium. In the second instance the loss of weight 
occurs because the food tolerance becomes lowered from 
the burden placed upon the digestive apparatus. Conse- 
quently assimilation becomes poor and the infant is prac- 
tically in the same position as if he were receiving less than 
the minimum. He starves from overfeeding because non- 
digestion means non-assimilation. In the last instance 
weight falls because not enough nourishment is provided. 
The digestive organs, however, having been given a chance 
to rest, the limit of food tolerance is increased as evidenced 
by our ability to gradually increase the strength and amount 
of the food. Reference will again be made to this fact. 
Thus, while these statements, based upon von Pirquet' s 
work, indicate that the digestive disturbances depend upon 
the fact that the food maximum- has been exceeded, they 
do not mean that any one particular ingredient is respon- 
sible in all instances. A clinical fact of importance is that 
it is often possible to feed large relative amounts of one 



106 ARTIFICIAL FEEDING. 

food element while, if all are relatively large, trouble will 
ensue. Thus, a high fat may be tolerated when fed alone, 
but when exhibited with a high protein or a high sugar, or 
both, may be responsible for fat indigestion. 

To exclude proteins as an etiologic factor of indigestion 
is a fallacy. Cases of this type do occur and are marked by 
definite symptoms. They are as common today as they 
were ten years ago, when, to the exclusion especially of 
sugar, nearly all digestive disturbances were laid at the door 
of this element. All so-called present-day curds in the stools 
are not fat. Clinical experience, very frequently, in spite 
of the researches of modem investigators, recognizes them 
as calcium paracasein, and they may be readily demon- 
strated toi be protein by the xanthoproteic test. It is as 
impossible today to feed relatively or absolutely as high 
percentages of chemically or mechanically unmodified cow- 
curds as it was years ago;, and to teach otherwise is danger- 
ous and cannot but lead to disaster. 

PROTEIN INDIGESTION OR INTOLERANCE. 

When an excess — and by excess is meant an excess for 
the individual, which in reality may be a small amount — of 
protein is fed to an infant, tolerance may persist for a brief 
period, to be followed by digestive disturbances and inter- 
ference with the nutrition. Protein excess is rarely marked 
by voimiting unless the amount be so' large that its speedy 
coagulation is followed by ejection from the stomach in the 
form of a tough, leathery mass within a short time after 
feeding. The main features of disturbance are confined to 
the intestinal tract. The stools are usually loose and green 
(Plate V). They have an unpleasant, but rarely foul 
odor, and contain considerable mucus and white or 



PROTEIN INDIGESTION OR INTOLERANCE. 107 

whitish-yellow masses of undigested calcium paracasein 
(curd). These masses may exist in an otherwise normal 
stood. This is not indigestio'U, but non-digestion of rela- 
tively too much curd. In this instance the curds act as a 
foreign body, and if their presence persists they may cause 
serioius intestinal irritation. These symptoms resemble the 
dyspepsia of Finkelstein, described by him as due to exces- 
sive fat or sugar. As before stated, the masses may be dis- 
tinguished as being protein by the xanthoproteic test. The 
babies have colic and are very irritable. 

In other instances, where too much protein is being 
fed, constipation exists, and the movements are hard, whitish, 
dry, and readily crumble (Plate VIII). They are passed 
with considerable effort, as a single mass covered with 
mucus, which may be blood-stained. Stationary weight or 
a loss is recorded in both these types of protein intolerance. 
The urine is often scanty, highly acid, and deposits of uric 
acid and urates are noted on the diaper. The temperature 
range in these cases is between 99° F. and iooJ^° F. or 
may be normal. 

Treatment. — An initial purgative of from i to 2 drams 
of castor oil should be given. An excellent substitute con- 
sists of equal parts of castor oil and the aromatic syrup of 
rhubarb. Of this substance double thei dose just indicated 
is to be prescribed. Initial purgation is followed by barley- 
water or whey feeding for twenty-four to forty-eight hours, 
or by weak tea sweetened with saccharin. In protein intol- 
erance initial purgation is valuable and without danger. 
(See "Diarrhea," Chapter IX, page 262.) Whey is 
practically a 5 per cent, solution of milk-sugar containing 
I per cent, of fat and i per cent, of soluble proteins. To 
the whey, properly heated tO' 150° F. in order tO' destroy 



108 ARTIFICIAL FEEDING. 

any remaining ferment, may now be gradually added small 
amioimts Oif plain milk or cream (split proteins). These, as 
tolerance is established, may be cautiously increased. 

In mild cases it may be unnecessary toi entirely eliminate 
the coagulable protein by whey feeding,' or whey feed- 
ing may not be continued long, a gradual return being made 
to the formula, starting with a weak mixture and gradually 
increasing. In this case it is advisable, for a short period 
at least, to piancreatize the formula (page 94). The time 
of pancreatization is gradually reduced and finally it is 
entirely omitted. After this the addition of some efficient 
digestive ferment to each bottle, just before feeding, is an 
excellent aid until the digestive function has been completely 
re-established. 

The early teaching of Jacobi^ advocating the use of 
cereal decoctions still holds good as an excellent means of 
rendering the paracasein easily digestible, and has received 
more recent emphasis from the work of Chapin, who em- 
ploys dextrinized gruels (page 86). The cereal decoctions 
provide a certain amount of starch, which, according to the 
investigations of Kerley,^ can be digested and assimilated 
by infants as young as 19 days. 

Ordinarily barley-water made from the grain is tO' be 
preferred, either full strength or diluted one-half with boiled 
water. If constipation be present, oatmeal-water makes an 
excellent substitute. In this connection the old-fashioned 
flour ball has rendered excellent service. It may be baked 
to a bread brown and, after being pulverized and sifted, 
added tO' each bottle just before feeding. At the same 
time a few grains of the very best extract of pancreatin 



1 Jacobi, A., "Therapeutics of Infancy and Childhood," p. 29. 

2 Kerley, C. G., "The Treatment of Diseases of Children," p. 126. 



PROTEIN INDIGESTION OR INTOLERANCE. 109 

may or may not be employed. If the pancreatin is not 
pure, the stools may become foul. Flour ball may also be 
used as follows: ^lA. to 5 per cent. O'f the total quantity of 
milk mixture is made to represent the amount of flour ball 
used. To this may be added 5 to 10 grains of pure pan- 
creatin, or the pancreatin may be omitted. A portion of the 
completed fonnula is rubbed while cold with the flour ball 
so that a smooth paste results. The remainder of the for- 
mula is brought just to the boiling point in a double boiler. 
It is poured over the moistened flour ball and, if pancreatin 
has been added, it is maintained at this temperature for 
fifteen minutes, when the mixture is again raised to the 
boiling point, allowed toi cool, and is bottled and iced. If 
no pancreatin has been added, immediately after adding the 
hot formula it is allowed tO' cool and iced without the 
second heating. The use of flour ball in this manner is, in 
the vast majority of cases, immediately followed by normal 
stools and a progressive gain in weight. A preparation on 
the market known as Benger's Food consists practically of 
pulverized flour ball and extract of pancreatin. It may for 
convenience be employed instead of the home-made flour 
ball. It gives excellent results as a curd modifier. I un- 
hesitatingly commit the heresy of recommending it. Both 
of these preparations are gradually reduced and finally 
omitted. 

Sometimes the simple boiling of the formula will ren- 
der the protein digestible, but must not be continued too 
long without the addition of fruit and animal juices to the 
dietary. 

Sodium citrate, gr. j to gr. iij, added to the formula for 
every ounce of milk and cream in the mixture, may render 
the curd digestible by causing it to remain fluid until it 



no ARTIFICIAL FEEDING. 

reaches the small intestine. Its effects are not immiediate 
and are usually revealed clinically within a few days. It is 
continued for some weeks, after which the amount is grad- 
ually reduced. 

As a further means toi oivercome the indigestibility of 
protein, the use of mechanically divided curd is of great 
service and permits of the feeding of unusually large 
amounts. For this purpose, buttermilk and eiweissmilch 
(pages 121 and 126), especially the former, serve admirably 
as temporary foods or "pick me ups." 

As already mentioned, Loeflund's mialt soup' as advo- 
cated by Keller is of service in removing protein masses 
from the stools in some cases. To' epitomize, therefore, 
the following may be stated as the means oif dealing with 
protein intoilerance : — 

1. Eliminate curd by whey feeding. 

2. Split protein — whey and cream' or whey and milk 
mixtures. 

3. Pancreatization. 

4. Cereal decoctions — plain or dextrinized. 

5. Flour ball alone or pancreatized. 

6. Benger's Food. 

7. Plain boiling. 

8. Sodium citrate. 

9. Buttermilk. 

10. Eiweissmilch. 

11. Loeflund's Malt Soup. 

FAT INDIGESTION OR INTOLERANCE. 

This, by Finkelstein, has been designated "weight dis- 
turbance" when occurring in its milder form. When of a 
more severe type, he calls it "dyspepsia," the symptoms of 



FAT INDIGESTION OR INTOLERANCE. HI ' 

which have been practicahy described as protein indigestion. 
No two babies can digest the same amount of fat. Diffi- 
culty is therefore experienced in attempting to arrange any 
set rule for the proper amounts of this ingredient to be fed. 
When intolerance occurs, the infant commences tO' vomit. 
The vomitus is soiir, smelling like rancid butter, and occurs 
from an hour tO' an hour and a half after feeding. The 
bowels are often loose and just as often constipated. In 
the former instance they are acid, green, or green and 
yellow, and greasy, co^ntaining mucus and lumps oif un- 
digested fat, that miay be mistaken for protein curds 
(Plates IV, V, and VI). These "curds," or masses, are 
softer, soluble in ether, burn w^hen dried, are blackened by 
Oismic acid, and are stained characteristically by Sudan III. 
The addition of a solution of Sudan III causes the fat par- 
ticles and oil globules tO' appear red under the microscope. 
When placed in water, oil droplets are found floating on 
the surface. 

When constipation occurs, typical soap stools (Plate 
VII) are found. The constipated stools are quite often 
solid, greasy, foul-smelling, and whitish or grayish white, 
or they may have a pinkish tinge (Plate VI). They fre- 
quently contain^ large or small granular masses 0)f hard 
calcium soap, sometimes ccKvered with mucus which may be 
blood-tinged (Plate VII). These stools result fromi the 
formation of fatty acids in the stomach and intestines. 
These acids combine with the mineral substances of the 
body and intestinal mucus. Thus a process of deminerali- 
zation obtains. The direct result of this is a prof ound effect 
upon the w^hole nutrition. The weight remains stationary 
or a slight loss is noted. The infant becomes anemic, weak, 
and the bones commence to' show evidences of poor 



i 



112 ARTIFICIAL FEEDING. 

ossification, and enlargement of the epiphyseal junctions 
(incipient rickets). 

The urine," on account of the large excess of fatty 
acids entering the blood and being there neutralized, be- 
comes highly alkaline and emits a decided am.moniacal 
odo'r. If this condition of acidosis continues, the digestive 
processes are all disturbed and intolerance for all food may 
ensue, tO' be followed by marasmus or decomposition 
(Finkelstein). As a rule the temperature remains normal 
or is only slightly elevated at times. 

Treatment. — An initial purgative of castor oil may or 
may not be valuable, depending upon the severity of the 
symptoms. In mild cases it should be withheld (''Diarrhea," 
Chapter IX, page 26y. The temporary course of barley- 
water or whey feeding may be of service. However, where 
the diagnosis is certain, all fat had better be at once 
eliminated following a period of starvation. This is accom- 
plished by the use of dilutions of fat-free milk (completely 
skimmed milk). These may be made half and half, or, 
better, i part of milk and 3 of water. Gradually, as 
tolerance is established, the dilution is made less and 
finally small quantities of cream may be added, or plain 
whole milk may be fed, at first well diluted. From; 2j^ 
to 5 per cent, of extra carbohydrate (sugar) is added. The 
fat is gradually increased, keeping well within the border oif 
tolerance. 

Where great acidity exists, marked by sour eructations, 
alkaline urine and soap stools, lime-water in quantities 
ranging from 5 to 25 per cent, should be added to all 
formulas. This seeks to prevent alkalinization, of the fatty 
acids by the tissues of the body, thereby preventing de- 
mineralization and acidosis. Fresh buttermilk forms an 



SUGAR INDIGESTION OR INTOLERANCE. 113 

excellent substitute! in fat intolerance. If made at home 
by the simple addition of lactic acid tablets, all cream should 
have been at first removed. The deficiency of caloric value, 
as the result of this, is made up by the addition of cane- 
sugar and wheat-flour in gradually increasing quantity 
(Chapter III, page 123). 

Pancreatization may overcome fat intolerance without 
necessitating a great reduction in the amount of fat fed. 
It must not be continued too long, or the very purpose for 
which it was used will be defeated. 

SUGAR INDIGESTION OR INTOLERANCE. 

Sugar has come into prominence as a great, if not the 
greatest, factor in the digestive disturbances of infancy. 
For reasons previously stated, personal experience does not 
permit of entire accord with this view. It has rarely been 
a source of trouble. The reason for this may be that 
rotitinely, following the teachings of Jacobi, cane-sugar, 
instead of the commercially impure lactose, has been em- 
ployed. Frequent, watery, acid stools that exco-riate the 
buttocks, associated with a sour, watery vomitus which 
irritates the esophagus and causes the infant tO' cry, together 
with flatulency and colic, are indicative of sugar indiges- 
tion. The urine may contain sugar; the baby may develop 
a high temperature and pass into a state of collapse on 
account of the frequent evacuations. A rapid loss of 
weight occurs, — intoxication ( Finkelstein ) . 

There are some infants who receive an excess of sugar 
and who do not suffer from indigestion, but grow fat. 
They are, however, flabby, anemic, and often develop 
rickets and scurvy at the same time, being subject to colds 
and to eczematous rashes. 



k 



114 ARTIFICIAL FEEDING. 

Treatment. — If the conditioin be acute and the symp- 
toms of intoxication severe, castor oil and starvation for 
twenty-four hours are indicated. In mild cases initial pur- 
gation is unnecessary and does harm. During this time 
cereal-waters or weak tea sweetened with saccharin, gr. j 
to the quart, are employed. If not acute, this preliminary 
treatment may be omitted. In this condition Finkelstein's 
eiweissmilch finds its greatest field of usefulness. It is, 
unfortunately, very difficult to prepare, except in institu- 
tions, and hence may be impracticable. A good substitute 
consists of equal parts of buttermilk and oif a wheat-flour 
solution (Chapter III, page 123). Both this and the 
eiweissmilch may be sweetened with saccharin, gr. j to the 
quart. The infant may be kept upon the buttermilk mix- 
ture for some time, and will gain, especially if gradually 
increasing amounts of cane-sugar or Dextri-Maltose are 
added. 

As far as the addition of extra carbohydrates to^ milk 
formulas is concerned, increasing experience with it seems 
to demonstrate the value of maltose. This is found on 
the market as Mead-Johnson's Dextri-Maltose oir as 
Loeflund's Food Maltose. Both are mixtures of dextrin 
and maltose. The latter is the more expensive, as it is an 
imported product. Both are used in the same manner as 
cane-sugar or lactose. A similar preparation is So'xhlet's 
Nahrzucker. 

Normal breast and bottle stools are shown in Plates 
II and III. 

DEFICIENCY OF FOOD ELEMENTS. 

This is marked by slow growth, stationary or losing 
weight, irritability, and usually by a subnormal temperature. 



FOOD IN IMPROPER QUAXTITJES. 115' 

unless the point of starvation is reached, when fever may 
occur. Constipation is the rule and the stools are normal 
in appearance, but of small bulk. Deficiency of food ele- 
ments may not mean deficient bulk. In fact, this most often 
is excessive, but then the milk mixture is weak. It must be 
remembered that, aside from the characteristic digestive 
disturbances, the same features of nutritional impairment 
may be brought about by unduly strong mixtures, the 
excess causing digestive disturbances which may:- prevent 
proper assimilation. The patient actually receives a defi- 
ciency of all the elements. Rickets and scurvy may follow 
a deficiency in fat, protein, and mineral substances. 

FOOD IN IMPROPER QUANTITIES. 

The average quantities of food have been stated pre- 
viously (page 102). A formula may be suitable to: the 
digestion of an individual, and yet be fed to him too fre- 
quently and in too' large amounts. This is just as often 
the cause of digestive disturbances as excessive amoants of 
any special ingredient. It is noted in breast-fed children 
whoi are nursed every time they cry. These babies are 
always irritable, vomit, have bad bowels, and often lose 
weight. This is true, especially of bottle babies. 

On the other hand, insufficient amounts of a correct 
formula may be given. These babies are always irritable, 
do not rest well, and, immediately after receiving the bottle, 
are unsatisfied, cry, and do not fall asleep at once as most 
babies do'. They usually have a stationary weight or lose 
a few ounces. Increase in the quantity of the food is im- 
mediately followed by a gain in weight. 



116 ARTIFICIAL FEEDING. 

FEEDING OF DELICATE AND SICK INFANTS. 

That this is a difficult problem gives no information, 
and yet in the handling of delicate babies who' are not act- 
ually ill, but only below par, general rules may be given to 
be applied to the individual case as the indications demand. 
The digestion of these infants must be carefully watched, 
and at the first sign of trouble it is wise to imm^ediately 
lessen the strength and quantity of the formula, or, perhaps, 
withdraw it entirely for twenty-four hours. Not a bad 
practice is to have the mother make the formula as here- 
tofore, but just before feeding to pour out of the bottle 
one-half or three-fourths or one-fourth and replace it by 
water. A gradual return is then made to^ the full strength. 
Quantities to be fed must be regulated according tO' the 
tolerance of the stomach and the appetite. While it is 
desirable to give the stomach absolute rest, many cases do 
better when fed small amounts frequently. Here the peculi- 
arities of the individual case must be studied. 

Infants sick, of diseases other than those depending 
upon feeding or disorders of the stomach and intestines, 
must have their food carefully watched, as they are excep- 
tionally prone to digestive upsets. Such an event may be 
the cause of a fatal outcome. In no disease is this better 
illustrated than in pneumonia, wherein an extensive and 
persistent tympanites oft'en closes the issue. In acute illness 
food should be withdrawn for twenty-four hours, and a 
return to the original strength not be made until after the 
crisis, or the main symptoms have subsided. If digestion is 
sluggish, the fo^rmula should be pancreatized and fed in 
small amounts. Overfeeding should never be permitted, 
and the infant is not to be disturbed too frequently, either 



FEEDING DELICATE AND SICK INFANTS. 117 

for food, medicine, or other attention. It is frequently 
advisable, when gastrointestinal symptoms arise, to with- 
draw milk altogether during the entire course of the illness, 
and keep the patient upon animal broths or juices, alone 
or in combination with cereal decoctions, thin gruels, or 
albumin-water. For a more detailed description of this 
topic see Chapter XIII. 



CHAPTER III. 

ARTIFICIAL FEEDING. 

(Continued.) 



IDIOSYNCRASY TO COWS' MILK. 

This is an actual condition. The smallest amount of 
cows' milk may, in susceptible individuals, cause symptoms 
of gastrointestinal derangement, sometimes accompanied by 
skin rashes. Though rare, the physician should be suffi- 
ciently familiar with the symptoms to recognize them. 
Kerley has reported a case. The history of the following 
case is of sufficient interest to warrant a somewhat detailed 
report : This was a healthy infant, nursed from the begin- 
ning by a wet-nurse. The fat in the nurse's milk ran as 
high as 8 per cent., causing frequent attacks of fat intoler- 
ance, which were always overcome by treating the nurse 
with purgati^^es and by restriction of her diet. It became 
necessary to dismiss the wet-nurse. A carefully adapted 
formula, a little weaker than her milk, was prepared. The 
infant refused it and cried persistently whenever the bottle 
was offered. It was impossible to make him close his lips 
about the nipple. On one occasion the nipple was held in 
his mouth for an hour and a half, the patient crying con- 
stantly. He finally took 2 or 3 ounces. Within five or six 
hours he had diarrhea, vomiting, an urticario-erythem,- 
;atous rash on his abdomen and legs, and a temperature 
of 101° F. The symptoms speedily subsided after the ad- 
ministration of castor oil and the withdrawal of the milk. 
The wet-nurse had to be recalled. After this any attempt 
(118) 



SUBSTITUTES FOR MILK FORMULAS. 119- 

to feed cows' milk was resisted and, when forced, was 
always followed by a rash and gastrointestinal symptoms. 
Weaning had tO' be finally accomplished by the direct feed- 
ing of solid foods and broths without milk. He is now 3 
years of age, and each time he partakes of cows' milk or of 
foods cooked with miilk he is troubled with digestive dis- 
orders and an eczematous eruption. 

These cases are probably anaphylactic in character, and 
represent an example of so-called allergia to cow-protein. 
Whenever an infant vigorously refuses cows' milk, this in 
itself should be definitely considered before pushing the 
food. In Kerley's case the first symptoms also followed 
the forcing of the milk upon the infant. Laboratory 
investigations may later disclose a method whereby this 
type of protein intolerance can be recognized by a skin 
test done after the manner of the von Pirquet reaction. 

SUBSTITUTES FOR MILK FORMULAS. 

Whey. — Whey is made by coagulating milk with ren- 
nin or essence of pepsin. To i pint of sweet or skimmed 
milk is added either 2 teaspoonfuls of liquid rennet or 
Fairchild's essence of pepsin. The milk is then placed upon 
the fire and gently heated to blood heat. It is then removed 
from the source of heat and permitted to clot. The clot 
is now broken up with a fork or a spoon, and the whole 
is filtered through 5 or 6 layers of narrow-mesh cheese- 
cloth, without pressure. Whey, when correctly made, is 
almost transparent and should be free fromi oil globules and 
flocculi of curd. 

When it is desired to^ feed a child upon a food in which 
casein is entirely eliminated, whey feeding miay be em- 
plo^^ed. It is easily digested and forms an admirable 



120 ARTIFICIAL FEEDING. 

vehicle in which to administer stimulants. It is an excel- 
lent substitute for milk in the management of some of the 
gastrointestinal disorders of infancy. It may be given plain 
or diluted with milk, barley-water, or cream (see below). 
Whey-and- Cream Mixtures (Split Proteins). — In the 
feeding of artificially reared children, the use of a whey- 
and-cream mixture may be of advantage. Before whey is 
added to cream or milk it should be subjected tO' a tempera- 
ture of 150° F. in order toi destroy the action of the ren- 
nin or pepsin. Otherwise the cream will curdle. The whey 
should not be subjected to a temperature higher than this, 
otherwise the lactalbumin will be coagulated. The mix- 
tures of whey and cream may be of service in instances 
wherein milk or milk formulas are not tolerated at all. 
The good effects are shown by a gain in weight and normal 
stools. These mixtures are only to be regarded as substi- 
tutes, and a return to milk should be gradually made as 
tolerance is indicated. The cream is added in gradually 
increasing amounts, starting with f3ss to f5j toi each bottle 
of 4 or 5 ounces of whey. Where it is desired to lessen 
the' amount of calciumi casein and to increase the whey- 
protein (lactalbumin and lactoglobulin), instead of whole 
milk in full strength, one may use sweet or skimmed milk 
diluted with varying quantities of whey. The proteins 
of whey equal about i per cent. Thus, if equal parts of 
whey and skimmed milk are added together, the resulting 
mixture would contain about 0.75 per cent, of whey-proteins 
and about 2 per cent, of calcium casein. These mixtures 
are also' of use where plain diluted cows' milk is not toler- 
ated. For practical purposes it is neither necessary nor 
useful to accurately calculate the percentages of split pro- 



SUBSTITUTES FOR MILK FORMULAS. 121' 

teins being fed. The guides are the infant's digestion and 
its weight. 

Wine Whey. — Four ounces of sherry wine are added to 
I quart of milk and the mixture boiled. Strain through 
cheesecloth. It is useful as a stimulant fed in small 
amotnits, plain or diluted with milk or cereal-water. 

Albumin-water. — Add the white of i fresh egg to a pint 
of water. Shake well. Strain. Salt and sugar to taste if 
desired. Feed plain or dilute with cereal water, or employ 
as a vehicle for fresh beef -juice, orange- juice, or brandy. 
When all milk is withdrawn, albumin-water, plain or 
modified, as above, serves as an excellent substitute article 
of diet, in the treatment of diarrhea cases or other types of 
indigestion. 

Sour Milk or Acidified Milk; Lactic Acid Milk; Butter- 
milk.— Milk to which lactic acid bacilli have been added, 
accidentally or intentionally, undergoes a process of fer- 
mentation whereby the different varieties of bacilli, of which 
the Bulgarian type is the most common, change the lactose 
toi lactic acid. This process is partial or complete as the 
time of fermentation is short or long. Accidentally soured 
milk should rarely if ever be employed, as there is great 
danger of pathologic bacterial infection being present, as 
well as obscure chemical processes which may cause serious 
trouble. Depending upon the amount of fat desired in the 
sour milk, whole sweet milk or skimmed milk, sometimes 
previously sterilized, is employed. Previous sterilization 
is usually to prolong the souring for too great a length 
of time. To the milk is added i or 2 of the many varieties 
of lactic-acid-bacilli tablets tO' be found upon the market. 
These are previously dissolved in a little milk or water. Of 
these the Lactone Tablets of Parke Davis & Co., or those 



122 ARTIFICIAL FEEDING. 

prepared by Fairchild Brothers & Foster, or the Bulgarian 
Tablets of Hynson & Westcott, have given satisfaction, 
although all of them-, at times, may be found tO' be inert. 
The milk is kept at room temperature overnight, after the 
tablet has been added. By morning, coagulation has oc- 




Fig. 24. — Home buttermilk churner. (Gimbel Bros., Phila., Pa.) 

curred. It is then beaten up, and is ready for use. If whole 
milk or cream has been used, after souring, it may be placed 
in a churner (Fig. 24) toi remove) the fat in the shape of 
butter, and the remainder, or the buttermilk, is decanted. 
Whole milk soured and simply beaten up, is erroneously 
designated as buttermilk. Soured skimmed milk more 



I 



SUBSTITUTES FOR MILK FORMULAS. 123 

closely approximates buttermilk which contains very little 
fat. The souring may be very conveniently brought about 
by simply adding to a quart of sweet milk a teaspoonful or 
two of sour milk. This is called a "starter," and takes the 
place of the tablet. Thus each day a little of the soured 
milk oif the day previous may be used for this purpose. 

The compiO'sition of these milks varies in fat content, 
depending upon whether they are made from whole sweet 
milk or skimmed milk. They contain approximately the 
same amount of protein as plain whole milk, and identical 
quantities of lactose which is considerably reduced by the 
fermentation. The composition of buttermilk varies, and 
derpends whether it be made by simply souringi skimmed 
milk or whole miilk ; or whether it is churned f rom^ sour cream 
or sour whole milk. It is poor in sugar and contains rela- 
tively more protein than fat. The protein exists in a finely 
divided state. 

Average Composition. 

Protein 3.0 per cent. 

Lactose 1.5 per cent. 

Fat 2.5 per cent. 

Salts 0.5 per cent. 

Prepared Buttermilk. — A preparation of buttermilk 
much used at the Philadelphia General Hospital (Blockley 
mixture) follows : Depending upon whether the living lac- 
tic acid organisms shall enter the infant's gastrointestinal 
tract 01* not, one of two' methods may be employed : — 

I. Three and three-fourths teaspoonfuls of wheat-flour 
are rubbed into a smooth paste with a little water, and suffi- 
cient water added toi make a quart; i^H teaspoonfuls of 
cane-sugar are dissolved in this. The whole is boiled for 
twenty minutes with constant stirring, the water of 



124 ARTIFICIAL FEEDING. 

evapoiration being replaced. Allofw it to cool. Add i quart 
* of soured whole or soured skimmed malk, or buttermilk. 

2. After mixing as above, the mixture is again brought 
to the boiling point. The flame must be low and, as soon 
as heat is applied, vigorous stirring is commenced and con- 
tinued until the boiling point is reached with but momentary 
interruptions; otherwise the curd will unite into a thick, 
tough, solid mass. At the end of the process sterile water 
is added tO' make the entire bulk equal 2 quarts. In this 
preparation the lactic acid bacilli are destroyed. 

The amount o-f cane-sugar added may be varied as the 
condition of the infant's digestion indicates tolerance or 
otherwise. It may be often advantageously omitted en- 
tirely, when the mixture can be sweetened with saccharin 
gr. j to the quart. Used in this manner, especially if sub- 
jected to the second boiling, it may iortn a good substitute 
for eiweissmilch, which it closely resembles. The purpose 
of the addition of the flour is to take the place of the defi- 
cient fat and assist in the foirmation of a finely divided curd. 
The additional sugar also; supplies heat and energy to- sup- 
plant that of the sugar lost by fermentation, and also' of the 
fat removed by churning. 

Indications. — These different varieties of lactic acid 
milk are useful in disturbances of digestion where difli- 
culty is experienced in taking care of the curd, or where 
a decidedly lessened amoomt of sugar is desirable. On 
account of the fine state of mechanical division in which it is 
found, the curd is rendered easily digestible. If fed raw, 
the additional effect of the lactic acid bacilli is secured. 
This may be of considerable assistance in tubercular 
enteritis. In one case the acid-fast bacilli were made to 
disappear. The more commonly useful mixture is the one 



SUBSTITUTES FOR MILK FORMULAS. 125 

to which flour and sugar have been added. It finds its 
special sphere in intestinal conditions marked by protein 
and fat intolerance. Green stools, curds, diarrhea, and 
iTDucus, associated with loss of weight and, at times, tem- 
perature, often speedily disappear after the use of this food. 
If they persist, before the mixture is discontinued it should 
be tried without the addition oi cane-sugar. In either in- 
stance the cessation of symptoms and the gain in weight, 
which may be a pound or more the first week, are at times 
only short of marvelous. Sugar may be cautiously added 
and slowly increased, after the stools become normal. 
Buttermilk milk mixture must not, however, be regarded as 
a permanent food. 

A time comes when the gain in weight is quite small or 
does not occur at all; at the sam,e time the infant seems to 
take a great dislike for the mixture which previously he 
had relished. A change must therefore be made to other 
food. This is done promptly, usually after omitting one 
feeding in order to^ allow the stomach tO' become completely 
eniipty. Either diluted skim milk (preferable at first) or 
diluted whole milk, with or without flour ball or Benger's 
Food, is substituted. Throughout the period of buttermilk 
feeding the infant receives from i to 2 drams of expressed 
beef -juice three times a day, as well as from i toi 2 daily 
inunctions of codliver or olive oil. Two' great advantages 
oif the buttermilk mixture are its cheapness and the ease O'f 
its preparation. It therefore has a great field of usefulness 
among the poor and among the ignorant. 

Buttermilk Conserve. — This comes in tin cans and re- 
sembles closely the mixture of buttermilk, wheat-flour, and 
sugar. It is thick and must be removed from the can as 
soon as the latter is opened. It is diluted with water. It 



126 ARTIFICIAL FEEDING. 

is a little more convenient therefore, especially while travel- 
ling, than the home-made mixture. Personal experience 
with it has been limited. The analysis provided by Biedert 
and Selter shows: — 

Proteins 9.6 per cent. 

Fat 0.6 per cent. 

Sugar 30.0 per cent. 

Salts 2.0 per cent. 

Lactic acid 1.7 per cent. 

Wheat-flour 4,5 per cent. 

Where cane-sugar seems to^ cause disturbance, use may 
be made of a buttermilk conserve containing Dextri-Maltose, 
marketed by Louis Hoos, of Chicago'. 

Eiweissmilch (Albumin Milk, Finkelstein's Milk, Pro- 
tein Milk.) — The following method of preparing eiweiss- 
milch is practised by Finkelstein in his well-equipped diet 
kitchen in the Waisenbaus u. Kinderasyl in Berlin: i tea- 
spoonful of any milk coagulant, as rennin or pepsin, is 
added to i litre of whole milk. This is thoroughly mixed 
and the vessel containing the material is placed in a water 
bath, the temperature of which is' about 110° F. This 
raises the milk tO' about 100° F. Within a short period 
coagulation occurs and the entire mixture becomes solid. 
The mass is then incised by a complete crucial incision. 
This facilitates the escape of the whey. The coagulum, is 
now placed in a suspension bag (made of either 4 or 5 
layers of cheesecloth or of a porous material resembling a 
thin, unbleached muslin) for a period of four hours. This 
permits all the whey to^ escape, carrying with it the major 
portion of the salts and the sugar of milk. The tough curd 
is then pushed through a hair-mesh sieve in order to com.- 
pletely comminute it. This process is accomplished with a 
wooden spoon, or with a druggist's pestle, or with a wooden 



SUBSTITUTES FOR MILK FORMULAS. 127 

instrument resembling a potato masher. It is repeated four 
or five times, adding about J4 litre of water tO' facilitate 
the passage through the fine sieve. One-half litre of good 
buttermilk is added to the finely divided coagulum, and the 
entire mixture is again passed through the sieve. The 
bulk of the product should equal i litre, and, should it not, 
the deficiency is supplied by adding sufficient water. The 
mixture is now brought to the boiling point, meanwhile 
stirring thoroughly mid constantly from the moment that 
heat is applied. This maneuver is crucial in its effect upon 
the perfection of the finished product. If it is not employed, 
the finely divided curd will become one solid mass. This 
accident seems to occur with great frequency in America, 
while in Finkelstein's kitchen it rarely ever happens. 
Whether this be due to the use of a special coagulant 
originally (Labessenz, made by Simon, Berlin c. Spandauer- 
strasse 17), or whether to the special and rather complicated 
apparatus which is employed to stir the mixture while it is 
being heated, is not quite clear, although I incline tO' the 
view that the latter is the case. In questioning the Sister 
in charge of the kitchen, on this point I could receive no 
definite information, chiefly, I believe, because she never 
experienced the difficulty. This special apparatus has a 
device which resembles an egg-beater, and for this, reason 
I have eniploiyed one of the latter with which tO' do^ the 
stirring while the mixture is being heated. The stirring 
must be continued during the process of cooling, which is 
accomplished more rapidly by permitting cold water to run 
over the containing vessel. Many American authors,; in 
giving their directions as to the manufacture of eiweiss- 
milch, omit the final boiling. This is incorrect and does not 
represent Finkelstein's views. In my own experience I have 



128 ARTIFICIAL FEEDING. 

been able, almost without exception, to prevent this coagula- 
tion en masse by adding a dram of raw wheat-flour tO' the 
mixture before apphang heat. While this practice too is 
irregular, it does not seriously interfere with the correct 
composition oif the eiweissmilch, and certainly does not 
hamper the clinical results. 

Composition. — Eiweissmilch is fat-poor, sugar-poor, 
and protein-rich. An average analysis follows: — 

Fat 2.5 per cent. 

Protein 3.0 per cent. 

Milk-sugar 1.5 per cent. 

Ash ■ 0.5 per cent. 

The calcium paracasein, or curd, is in a finely divided state. 
The milk is sterile. Eiweissmilch contains less sugar than 
buttermilk. 

The difficulty experienced in preparing eiweissmilch in 
the home has caused its manufacture to be undertaken on a 
large scale in Germany. In America and alsoi in Germany 
it may be found upon the market in powdered formi; 90 
grams of this preparation are added to 1000 cubic centim- 
eters of previously boiled and cooled water, and thoroughly 
mixed. 

Larosan is also' a substitute product. It is eiweiss cal- 
cium, or a combination of the protein of milk and lime. 
About 2 per cent, is added to J^ litre of water. To this is 
added y^ litre of whole milk and the entire mixture is 
boiled. It is employed to correct dyspeptic stools before 
resorting immediately to eiweissmilch. Additional carbo>- 
hydrate in the form of cane-sugar or of Dextri-Maltose may 
be added if desired. (See Diarrhea, Chapter IX.) 

Uses. — Although usually employed full strength, eiweiss- 
milch may be diluted. On account of its deficiency of 



PLATE IX 




Stool of a case of diarrhea discolored by bismuth. Notice 
absence of fecal matter and the excess of mucus. Artificially 
fed baby; stool commonly seen in intoxication. (See text for 
treatment of sugar intolerance and diarrhea.) 



SUBSTITUTES FOR MILK FORMULAS. 129 

sugar, it may be rejected by some infants. In order to 
O'vercome this i grain of saccharin may be added to^ a quart. 
To increase its caloric value the addition of sugar in the 
form of Loeflund's Maltose or Mead- Johnson's Dextri- 
Maltose is usually made. At first 2^ per cent, and then 
5 peir cent, is added, four or five days after starting the 
feeding, or when the bowels become normal. 

Evweissmilch undoubtedly finds its greatest field of use- 
fulness in the treatment of summer diarrhea and next in 
cases of infantile dyspepsia, mherein difdcidty is experienced 
in the proper digestion of the protein or fat, or both. 
It is by no means toi be regarded as anything but a tem- 
porary food, although some children gain slightly on it. 

Its effect on the diarrhea and character of the stools is 
almost immediate. From 8 tO' 10 or more movements a day 
the number is speedily reduced and their appearance be- 
comes whitish or brownish yellow, and constipated (calcium 
soap stools, caseate oi lime). This change is so' constant 
that it cannot be regarded as accidental. Maltose is not 
added to the milk until the stools are no^rmal. From 
eiweissmikh the change is made to the required dilution of 
zuhole or of skimmed milk immediately, as zvith buttermilk, 
but one feeding being omitted to allow the stomach to empty 
itself. 

Ramogen, a conserve, marketed in cans, represents 
a condensed form of Biedert's creamh-and-whey mixture, 
the basic idea of which is tO' seek a combination of protein 
and fat acceptable to the infantile digestive apparatus. The 
relative proportions of protein, fat, and sugar in Ramogen 
are based upon the principle of the amount of food neces- 
sary for growth. The fat is rendered easily digestible by a 
process of emulsification. The proteins are not predigested. 



130 ARTIFICIAL FEEDING. 

The conserve is obtained by condensation at a low tempera- 
ture. It is sterile. Cane-sugar is added as a preservative. 
The reaction of Ramogen is slightly alkaline. Its com- 
position represents: — 

Proteins 7.0 per cent. 

Fat 16.5 per cent. 

Sugar 34-65 per cent. 

Salts 1.5 per cent. 

This substance is especially useful in some cases of dehcate 
digestion associated with marked disturbance of the nutri- 
tional balance. Cases of decomposition (marasmus) which 
have passed the gamut of patented foods and do' not seem 
able to digest cows' milk formulas, however manipulated, 
have shown a remarkable gain in weight and passed on to 
complete recovery when placed upon this food. It also' does 
well in many cases of summer diarrhea after the acute 
symptoms have subsided, following the period of barley- 
water or weak-tea feeding before milk formulas are again 
resumed, and where sugar is well tolerated. 

Ramogen is employed by diluting it either with water 
(to be preferred) or with milk. The following dilutions 
are suggested : — 



Age. 


Mixture. 


Calories 


Percentages of 




Ram. 


Water. 


in 100 c.c. 


Proteins. 


Fat. 


Carbhd 


First 3 weeks 




13 


25 


.52 


1.23 


2.7 


3 to 6 weeks 




11-12 


27-26 


.56-.53 


1.36-1.3 


3-2.8 


6 to 9 weeks 




10 


30 


.63 


1.48 


3.1 


9 to 15 weeks 




9 


33 


.7 


1.65 


3.46 


15 to 18 weeks 




8 


35 


•77 


1.81 


3.8 


18 to 21 weeks 




7/2 


38 


.81 


1.93 


4.0 


21 to 24 weeks 




7 


41 


.87 


2.06 


4.3 


24 to 27 weeks 




6^ 


43 


•93 


2.19 


4-7 


27 to 33 weeks 




6 


45 


.98 


2.31 


4.8 


33 to 49 weeks 




5^/^ 


50 


1.07 


2.54 


5.3 


39 to 44 weeks 




5 


54 


1.15 


2.72 


5.7 



SUBSTITUTES FOR MILK J-OkM LLAS. 131 

Age. Mixture. Calorics Percentages of 

Ram. Water. Milk, in lOO c.c. Proteins. Fat. Carbhd. 

4 to 6 weeks i I2j^ 2 30 .92 1.39 2.5 

6 to 9 weeks i 12 3 33 1.17 1-54 2.8 

9 to 15 weeks i iij/^ 3>^ 35 i-29 1-64 2.88 

15 to 18 weeks in 4 37 i-42 i.74 3-0 

18 to 21 weeks i 10^ 4^ 39 i-54 1.83 3-i2 

21 to 24 weeks i 10 5 4i i-66 1.92 3.24 

24 to 27 weeks i 9^ 5>^ 43 1.78 2.01 3.36 

27 to 30 weeks 196 45 1.92 2.1 1 3.5 

30 to 33 weeks i 8J^ 6^ 47 2.0 2.19 3.6 

33 to 36 weeks 187 49 2.18 2.24 3.76 

33 to 39 weeks i 7'/ 73^ 5i 2.3 2.4 3-9 

Somatose Milk.— This contains : — 

Proteins 8.8 per cent 

Fat 16.5 per cent. 

Carbohydrates 34-6 per cent. 

Salts 1.5 per cent. 

It is practically Ramogen containing lactosoinatose, which 
is an albiimose of casein and contains 5 per cent, tannin in 
firm chemical combination. Its purpose is supposed tO' take 
the place of the soluble lactalbumin in mother's milk, which 
plays an important factor in the easy digestibility of the 
curd. It is very readily assimilable. 

Indications. — It is useful in all cases of weak digestion, 
in acute, subacute, and chronic inflammation of the intes- 
tinal tract, and in wasting diseases, as essential marasmus, 
scurvy, and rickets. It is employed in the same dilutions as 
Ramogen. 

Condensed Milk. — Milk evaporated in vacuo, after 
sterilization, constitutes condensed milk. It may be sweet- 
ened or unsweetened, fresh or sold in cans. The last is the 
product commonly used. It contains a large amount of 
carbohydrate, mainly in the shape of cane-sugar, which is 
added as a preservative. When the can is opened the con- 



132 ARTIFICIAL FEEDING. 

tents should be poured into a china or glass pitcher. It is 
kept co^^ered on ice, and should not be used after the 
•second day. Its composition, according to- the manufac- 
turer, is as follows : — 

Fat 9.61 per cent. 

Protein 8.01 per cent. 

Carbohydrate (42.91 per cent, cane-sugar, 

12.03 per cent, lactose) 54.94 per cent. 

Salts 1.78 per cent. 

Water 25.66 per cent. 

loo.o per cent. 

Condensed milk is rich in sugar and poor in fat, proteiUj 
and inineral salts. It has been a very much unjustly con- 
demned food and, at the same time, a very much overused 
one. Infants fed exclusively on condensed milk grov^ fat, 
but have poor resisting powers, readily succumb tO' the 
acute infectious diseases and pulmonary trouble, and fre- 
quently develop rickets and, less often, scurvy. They are 
often anemic. Nevertheless condensed milk, properly 
diluted to the digestive capacity (about i part in 12 or 16 
of water at the outset, increasing the strength up to abont 
I in 6), is a valuable adjunct to our feeding armamen- 
tarium. It is best given diluted with a cereal-water. Where 
protein or fat intolerance exists, this food is often valuable. 
Especially has it been found useful in some cases of summer 
diarrhea as a go-between, as it were, between the starvation 
period and the time when a return is made tO' fresh milk 
formulas. Condensed milk should only be employed in 
those cases of summer diarrhea zvhere it can he proven that 
the condition is not dependent upon sugar intolerance. 
After the acute symptoms have subsided a weak dilution ol 
condensed milk is made with barley-water. This is grad- 
ually strengthened, and one bottle of the condensed-milk 



CURD MODIFIERS. 133 

feeding is daily or bidaily replaced by a weak fresh-milk 
fomiula, until all are replaced. The fresh-milk mixtures 
are then slo'wly strengthened. Condensed milk is cheap. 
It therefore must often be considered when feeding the 
poor, especially in rural or semiriu-al districts, and also- in 
summer, as it is practically sterile and requires only the 
addition of a sterile diluent. When travelling for a long 
distance, it, alone, may be depended upon. When continued 
over any length of time, it must always be supplemented by 
the feeding of fresh fruit- or vegetable- and beef- juice. 

Soya Bean.— This has been much advocated by Ruhrah. 
The bean is made intO' a flour by the Cereo Company of 
Tappan, N. Y., and contains 44 per cent, protein, 20 per 
cent, fat, 10 per cent, cane-sugar, and a trace of starch. 
In infancy it has been recommended as a gruel : 4 tO' 8 
level tablespoonfuls and a pinch of salt are added to i 
quart of water. Boil fifteen minutes. Strain. Add water 
to a quart. Cool. It may be used in this manner or added 
tO' milk. In order tO' prevent the gruel from settling, i to 2 
teaspoonfuls of barley-water may be added. This adds 0.6 
per cent, to 1.2 per cent, of starch. 

CURD MODIFIERS. 

The following substances, useful as additions to or sub- 
stitutes for cows' milk, merit special mention as mechanical 
modifiers of the curd of cows' milk: — 

Flour Ball (Plain). — One pound of clean wheat-flour 
is tied in the shape of a ball in a bag made of unbleached 
muslin or balbriggan. The foot of a new, white stocking, 
size 10, will answer. It is placed in water and boiled con- 
tinuously for eight hours. At the end of this time it is 
removed from the bag and placed on a plate in an oven and 



134 ARTIFICIAL FEEDING. 

slowly but completely dried out. It will appear with an 
outer skin, as shown in Fig. 25. It is now cracked, opened, 
and the inside is grated or pulverized and sifted. The pul- 
verized flour ball is added to each bottle just before feeding, 
in the amount of from J^ tO' i teaspoonful, or it may be 
used as detailed in Chapter II, page 108. 

Flour Ball (Dextrinized or Browned). — This is made as 
just described, except that after breaking open the ball is 
baked to a "bread brown" and this portion is grated and 



A 






ifl^^ 


^*^^^ 


W^ 


*w^ 


"""^^^^B 


/ B 
A 


B 


^ 


A 



Fig^ 25. — Flour ball. One is cracked open into three pieces. The inside 
(B) is pulverized and sifted. The hard shell (A) is discarded. 

sifted. This baking process is repeated as often as neces- 
sary. Flour ball will keep indefinitely, provided it is kept 
perfectly dry and in an air-tight container. This is to pre- 
vent the growth of mold. 

Uses. — This, an old-fashioned, time-honored ''grand- 
mother's remedy," has, unfortunately, been almost for- 
gotten and passed into disuse. It is an excellent agent 
to add to the foniiula where the infant cannot digest the 
curd of the milk. It is especially healing and soothing when 
this condition is associated with diarrhea. When constipa- 
tion supervenes, the amount of flour ball should be grad- 
ually lessened and finally omitted. Browned or dextrinized 



CURD MODIFIERS. 13S 

flour ball should be used in those cases where the plain 
flour ball produces too much gas, as it may in infants who 
cannot digest starch very well. In addition, in these in- 
stances, when the simple browning is insufficient, i or 2 
grains of Fairchild's extract of pancreatin may be added to 
each bottle. 

Benger's Food. — Though a proprietary, as a curd modi- 
fier this food may justly find a permanent place in the 
dietetics of infancy. It consists simply of extract of pan- 
creatin and of pulverized flour ball, and may be conveniently 
used as a substitute! for it, as the loiig time required for the 
preparation of the latter is thus omitted. This food is used 
in the proportion of 5 per cent, of the total formula or less, 
usually less (2j^ per cent). The ingredients of the for- 
mula, with the exception of the Benger's Food, are mixed 
in the usual mianner. A small quantity of the mixture, 
about an ounce or two, is rubbed into a smooth, paste with 
the Benger's Food. The remainder of the formula is 
brought to the boiling point in a double boiler.^ This is 
then poured over the paste. Mix well; allow to stand 
fifteen minutes without fire, but covered. Heat quickly a 
second time to the boiling point in a single boiler placed 
over a low flame. Stir the mixture constantly to prevent 
burning. Cool. Bottle. Ice. 

The effect upon green stools is almost immediate, chang- 
ing them to a smooth yellow, with a normal or slightly acid 
reaction. The amount of Benger's Food is gradually re- 
duced and finally omitted. The only objection to the use 
of this preparation is that the milk must be boiled. In sum- 



1 It must be remembered that substances do not actually boil in a 
double boiler. They simply steam and bubbles are seen about the 
edges ; or the temperature may be taken with a thermometer. 



136 ARTIFICIAL FEEDING. 

mer this is an advantage. If the necessity for its prolongeil 
use exists, fruit- and meat- juices must be fed to^ the infant. 
Imperial Granum. — P>om i to 2 tablespoonfuls of Im- 
perial Granum are added toi i pint of milk and boiled one- 
half hour. At the end of this time the addition of a suffi- 
cient quantity of water is made toi bring the total volume 
up to a pint. As a cereal-water Imperial Granumi is a use- 
ful curd modifier, and adds materially tO' the nutrition of 
the fonnula on account of the extra starch, which most 
infants are able to digest at a very early age (Kerley). 
This preparation must also^ be reinforced by the feeding of 
meat-, vegetable-, and fruit- juices. 

SUBSTITUTES FOR MILK-SUGAR. 

For reasons previously stated the milk-sugar of com- 
merce frequently forms a poor substance with which tO' pro^- 
vide extra carbohydrate. For this purpose other sugars 
have been employed. 

Cane-sugar (Saccharose) in many instances is an excel- 
lent substitute. Experience with it has verified all that is 
claimed for it by Jacobi. One ounce equals about 120 
calories. 

Mead's Dextri-Maltose and Loeflund's Food Maltose. — 
Malt-sugar, or maltose, is more rapidly absorbed than 
either lactoise or saccharose. The degree of assimilability 
of these three sugars is indicated as foillows: — 

Maltose 7.7 grams + per kilogram (Ruess). 

Lactose 3.1 to 3.6 grams per kilogram (Gross). 

Saccharose About the same as lactose (Ruess), 

The power to assimilate maltose is therefore double that of 
the other two. It has been further shown that larger 
amounts of maltose can be taken by the infant than either 



SUBSTITUTES FOR MILK-SUGAR. 137 

of lactose or saccharose, without sugar appearing- in the 
urine. This is probably due to the fact that maltose, ab- 
sorbed as such into the body, is acted upon by a special 
ferment found in the muscles, blood, and other tissues. 
Maltose causes a more rapid gain in weight. Its conibina- 
tion with dextrin increases this power. It does not readily 
ferment in the intestinal tract. For dietetic purposes, how- 
ever, pure maltose is inaccessible on account of its expense. 
It therefore appears on the market in combination with 
dextrin in the shape of Mead-Johnson's Dextri-Maltose and 
as Loeflund's Food Maltose. These resemble each other 
closely; the latter being imported, is therefore more ex- 
pensive. They are each added to^ the formula in any extra 
percentage desired, from i to 5 per cent. ; i ounce to a 20- 
ounce mixture equals 5 per cent, extra carbohydrate. 
When maltose is employed the stool is often characteris- 
tically brown or brownish yellow. One ounce of either of 
these preparations approximates 120 calories. 

Composition of Dextri-Maltose. — This practically con- 
sists of starch converted by malt diastase, the percentage of 
maltose and dextrin being respectively regulated by the 
temperature at which the process is stopped and the length 
O'f time of exposure to^ this temperature. It contains 
neither cellulose, protein, nor fat : — 

Maltose 51.0 per cent. 

Dextrin 42.7 per cent. 

Salts 2.0 per cent. 

Moisture 4.3 per cent. 

Composition of Loeflund's Food Maltose. — Loeflund's 
Food Maltose contains, approximately: — 

Dextrin 60.0 per cent. 

Maltose 40.0 per cent. 

Salts 0.3 per cent. 



138 ARTIFICIAL FEEDING. 

Soxhlet's Nahrzucker. — This preparation is marketed 
by the Arcady Farms of Lake Forrest, 111. It is added as 
extra carbohydrate in the amounts of i tO' 5 per cent, oif the 
milk formula. It is called nutrient sugar, and was elab- 
orated by Prof. Dr. Soxhlet. It is dissolved in boiling 
water. The milk and other ingredients of the formula are 
added and the whole sterilized. Its composition is similar 
to Dextri-MaltO'Se and Food Maltose. 

FEEDING AFTER THE FIRST YEAR. 

At 12 months an infant should be receiving whole, un- 
diluted, cows' milk. At this time additions should be made 
to the dietary in the shape of cereals, and other foods to be 
detailed. This statement bears modification in so far as 
some iinfants are able to digest whole milk at an earlier 
age, and, at the same time, to^ receive foods that require 
chewing. Others, again, may not be able to take care of 
strong food at this time. It is clearly a problem of the 
individual. Many children beyond a year of age are seen 
whose nutrition has suffered for the want of strong food, 
and who are weak and undernourished. In these cases a 
change in diet to solids is productive of marvelous results. 
On the other hand, it must not be forgotten that malnutri- 
tion results as well from overfeeding as feeding an infant 
things which it cannot digest. How are we tO' judge, and 
what are the guides! tO) indicate that the gastrointestinal 
tract is ready for the digestion oi food that requires com- 
minution? Aside from the condition of the general health 
and of the digestion, the one single thing that would indi- 
cate digestive strength is the presence of several teeth. 
This is a safe indication to- commence the feeding of solids 



FEEDING AFTER FIRST YEAR. 139 

and semisolids irrespective of the age, provided the infant 
is not suffering from indigestion. 

The use of the bottle should not be permitted beyond 
12 months in most instances, and promptly at this time the 
infant may be taught to take its milk from a cup. Some 
babies take and relish other food, especially thin cereals and 
nisk or zweiback, as early as 6 months, but as a general 
proposition the end of 12 months is the best time to 
commence extra feeding. A practical point of importance 
is the statement frequently volunteered by the mother, that 
her baby will not take this or that food. The acceptance of 
foods other than the bottle is a matter of education, and the 
baby must get used to the new substances. Thus, an infant 
may refuse an egg. It should not be forced, but one should 
be offered to it again in a few weeks or a month. The 
additions to the food should be gradual and should consist 
primarily of well-cooked cereals, as oatmeal, cream of 
wheat, and cornmeal. These should be cooked at least two 
hours, with or without milk, and served either with milk 
and sugar or with butter or meat-juice. Rice is a useful 
cereal at this time, but must be cooked at least three hours. 
Mashed baked potato (page 147), with milk and butter or 
beef-juice, is of value. Bread and butter may also be 
allowed. For desserts, junket or rice-, sago^, or other pud- 
ding, or mashed baked apple, or the inside of prunes, may be 
used. At this age infants should receive not more than five, 
and better but fonr, meals a day, so arranged as to give 
plenty of rest for the stomach, and that the heaviest meal 
should be given in the middle of the day and the lightest 
at night. The schedule appended has given uniform 
satisfaction : — 



140 ARTIFICIAL FEEDING. 

Diet No. i. 
Diet for \ge 

Date 

Breakfast (6.30 to 7 a.m.). — (i) Glass of milk and stale bread 
broken in it. (2) Cereal, as oatmeal, arrowroot, rice, grits, cooked at 
least two hours (rice, three hours), and covered with milk. If desired, 
can be sweetened to taste. (3) Soft-boiled egg and bread and glass of 
milk. 

Second Meal (10 a.m.). — Milk. 

Third Meal (2 p.m.). — (i) Beef-blood, beef-tea, or fat-free gravy 
containing stale bread broken in it, and a glass of milk. (2) Rice and 
grits cooked three hours or mashed baked patato with beef-tea or beef- 
blood or gravy. (3) Soft-boiled egg, buttered stale bread, and glass of 
milk. Rice-, sago-, or other pudding, or junket, can be given for 
dessert; mashed baked apple. 

Fourth Meal (5 p.m. to 6 p.m.). — Glass of milk or milk and crackers. 

Fifth Meal (9 to 10 p.m.). — Glass of milk. 

This diet should not be used beyond the age of 18 months. 

The fifth meal may preferably be omitted and the time of 
feeding indicated may be adjusted to fit the routine of the 
household. If an infant has been kept on the breast up tO' 
the age of 12 months or longer, the change to this diet may 
be made at once, except that, where it calls for milk, diluted 
milk may be given at first. If an egg be given for breakfast, 
it should not be given at the midday meal, one a day being 
ample. 

At the age of 18 months, further additions may be made, 
especially at the midday meal. Soups made from muttom, 
fish, of chicken, either plain or containing a cereal or vege- 
table, are valuable. The most important addition is meat 
in the shape of finely cut, rare, broiled steak; lamb-chop', 
roast beef, boiled fish, or white meat of chicken. Desserts 
may include custard and bread-pudding. Only three prin- 



FEEDING AFTER SECOND YEAR. 141 

cipal meals a clay are given, with a very light lunch between, 
at 10 A.M. and at 4 p.m. : — 

Diet No. 2. 



Diet for Age 



Date 



Breakfast (7 to 8 a.m.)- — (i) A slice of bread and butter or soda 
or graham cracker, or shredded-wheat biscuit with a glass of milk. (2) 
Soft-boiled egg, glass of milk, bread and butter. (3) Oatmeal, arrow- 
root, wheat-grits, hominy, cream of wheat (farina), cooked at least two 
hours with milk; glass of milk. 

Lunch (10 A.M.) — Glass of milk with stale bread, zweiback or 
cracker, buttered if preferred. 

Dinner (2 p.m.). — (i) Rice boiled three hours, with meat-gravy or 
milk, or mashed baked potato moistened with butter or beef-juice; 
glass of milk. (2) Clear vegetable soup or soup made from mutton, 
lamb, fish, or chicken, clear or containing rice, celery, sago, farina, or 
stale bread or crackers broken in it ; bread and butter, and rice-, sago-, 
or bread- pudding; custard, junket, apple-sauce, or stewed prunes 
(pulp), as dessert. (3) Soup, small piece of finely cut white meat of 
chicken, broiled lamb-chop, tender steak, roast beef, or boiled fish, bread 
and butter, and dessert. 

Afternoon Meal (4 p.m.). — One to three lady fingers, or piece 
zweiback. 

Evening Meal (6 p.m.). — Bread (plain or buttered) and milk. 

This diet is not to be used beyond 2 years. 

FEEDING AFTER THE SECOND YEAR. 

The diet now commences to- assume more of the char- 
acteristics of that of the adult, in that a greater variety of 
food is. allowed. The afternooin luncheon is often omitted. 
Occasionally a little pure ice-cream and a lady finger are 
alloiwed. Between 7 and 8 a.m. breakfast is serv^ed and con- 
sists of orange- juice, scraped raw apple, raw ripe or stewed 
peaches, apple-sauce, California grapes freed of skin and 
seed, baked apple or stevred prunes, cereal — as oatmeal, 



142 ARTIFICIAL FEEDING. 

hominy, wheaten grits, cream of wheat, or other porridge; 
a small portion of finely cut beefsteak (broiled) or lamb- 
chop, and bread and butter and a glass of water. If meat 
be omiitted, and it should be if fed at noon, an egg and a 
glass of milk may be substituted in the morning. At lo 
A.M. the child may receive its bath, to be followed by a 
small glass of milk and a cracker, or a small cup of broth. 
Its morning nap follows. Dinner is served at 1.30 or 2 
P.M., and consists of soup, a meat, two vegetables., bread 
and butter, dessert, and a glass of moderately cold, pure 
water. The varieties for selection are noted below. At 
6 P.M. a supper consisting of bread and butter and milk, or 
bread and butter and apple-sauce and water, is given : — 

Diet No, 3. 



Diet for Age 

Date 

Breakfast (7 to 8 a.m.). — (i) Orange-juice, scraped raw ripe 
apple, raw ripe or stewed peaches, apple-sauce, grapes freed of skin and 
seeds, baked apple or stewed prunes, oatmeal, hominy grits, wheaten 
grits, cream of wheat, or other cereal porridge, well cooked and served 
with plenty of milk and sugar to taste ; small portion of finely cut 
broiled beefsteak or lamb-chop, with bread and butter. (2) Cereal and 
fruit as above, with soft-boiled or poached egg, with bread and butter 
and a glass of milk. 

Second Meal (10.30 a.m.). — (i) Glass of milk, with bread and but- 
ter, or soda cracker. (2) Bread and milk or graham crackers and milk. 
Chicken- or mutton- broth, with bread or crackers. 

Dinner (1.30 p.m.), — Clear soup made from beef, chicken, lamb or 
fish, or soups containing well-cooked rice, barley, farina, celery, or 
noodles, or oyster- or clam- broth ; roasted or broiled or stewed chicken, 
turkey, squab, beef, lamb, fresh fish cut fine ; mashed baked potato with 
butter or beef-blood on it; stewed celery; asparagus tips; spinach 
(German style); stewed noodles with milk dressing; stewed onions; 
skinned and mashed peas and lima beans; creamed squash; bread and 
butter. As dessert, rice-, sago-, tapioca-, farina-, or plain bread- pud- 



DIFFICULT FEEDING AFTER FIRST YEAR. 143 

ding; junket, egg-custard, or cornstarch, or any of the fruits mentioned 
above, (Selection for dinner should consist of a soup, one meat, not 
more than two vegetables, bread and butter, and dessert.) 

Supper (6 p.m.). — Bread and butter and milk, or crackers and milk, 

Diet not to be used for child under 2 years. 

If absolute regrilarity is practised at this time and no 
departure is made from the foods contained in the hst 
appended, there will be no digestive derangements. Over- 
feeding or yielding to the importunities of the child will 
only bring disaster to it and sorrow to the ho»usehold. Tea, 
coffee, pastries, and an undue amount of sweets, a piece 
of chocolate being allowed each day, fresh bread, beer, 
alcohol in all forms, made dishes, smoked oir pickled foods, 
cheese, bananas, an excessive amount of cakes and ice- 
cream should find nO' place in the child's dietary, even up to 
the age of 5 o*r 6 years. It is just as easy tO' train a child 
toi eat and tO' relish the correct foods as it is toi allow it to 
eat indigestibles. The gain to its digestion and nutrition is 
increased many fold. 

DIFFICULT FEEDING CASES AFTER THE 
FIRST YEAR. 

In those children who' cannot take whole milk. Diet 
No. I may be given with the breast or with diluted m.ilk, or 
with no milk at all. These cases often follow an attack of 
summer diarrhea late during the first year, or during the 
first half of the second year. A return to milk means a 
renewal of symptoms, and main reliance must be placed 
upon mutton- or beef- broth, cereals — as rice and farina, 
and stale bread, and eggs. A diet of this kind will often 
cause the stools to become normal without the use of medi- 
cation. The return to milk must be made with the utmost 
caution, using it boiled at first and well diluted. 



144 ARTIFICIAL FEEDING. 

Again, cases of delicate digestion occur, in which it is 
impossible to place one's finger exactly on the cause. All 
that can be said is that the children are delicate. Here 
individual experience and experience with the individual 
child, alone can be our guide. The dietary miust be carefully 
scrutinized, and each article that seems toi disagree must be 
eliminated. The stools must be carefully studied in order 
to learn what substances pass undigested. As a rule, 
highly seasoned or overfatty foods cause disturbance. In 
no instance should the evening meal be large, and great care 
to prevent overfeeding should at all times be taken, the 
preferable idea being to give several small meals. Where 
vomiting occurs as a frequent symptom, proteins are to be 
avoided, as they may be responsible for an increased 
acidosis, as shown by acetonuria, and the acid fruits and 
carbohydrates are toi be especially pushed. Where night- 
terrors occur, with febrile attacks and indicanuria, reduce 
the proteins and sugars and increase the supply Of water. 
During an attack of fever all food had better be withdrawn, 
oir at best the diet reduced to simple liquids (Chapter XIII). 

FOOD RECIPES. 

Beef-tea No. i. — Toi i pound of lean chopped beef, free 
of fat, add i quart oi water. Boil one hour, renewing the 
water from time to time. Strain. Cool. Remove fat. 
Salt tO' taste. Warm before feeding. Fresh daily. 

Beef-tea No. 2. — To' i pound of lean chopped beef add 
I quart of boiling water. Keep warm one-half hour. 
Strain. Place on ice. Remove fat. Salt to taste. Warm 
before feeding. Fresh daily. This is more rapidly made 
than No: i. 

Both may be used as substitute articles of diet, plain or 



PLATE X 




Same case as Plate IX. Diarrhea more advanced. Note 
blood and mucus ; some green and discoloration by bismuth. 
Very little milk feces present. 



FOOD RECIPES. 145 

in combination with white of tgg, egg-water, cereal-water, 
or a small amount of the cereal itself may be added. For 
older children celery or onion flavoring may be used. 

Expressed Beef-juice. — Cut into squares one-fourth to 
one-half pound of fresh lean beefsteak. Rump or round 
will dot. Place in a clean pan without fat or butter, and 
heat until the pieces of meat are just "whitened" on all 
sides. Express the beef ''juice" or blood with a clean 
lemon-squeezer. Salt to taste. Keep on ice. Remove fat. 
Give infant from fSss toi f5ij three times a day on an empty 
stomach. Exactly one-half hour before feeding is to* be 
preferred. Before feeding it, heat by placing the desired 
amount in a spoon and holding the latter over some steam. 
If the juice changes color and becomes brown it has been 
heated too much and must be discarded for other. The 
purpose O'f heating is to warm it — not tO' cook it, otherwise 
the purpose for which it was given will be lost. Expressed 
beef -juice should be fed tO' all bottle babies after the second 
or third month, and should be continued until after the 
nursing period. Most infants enjoy it. It prevents, and 
assists in curing rickets and scurvy. 

Mutton-broth. — To i pound of fresh, lean, chopped 
mutton add i quart of water. Boil one hour. Renew 
water as it evaporates. Strain. Cool. Remove fat. Salt 
to taste. Fresh daily. Warm before feeding. Useful in 
cases of diarrhea, alone or in combination with egg-albumin, 
cereal-water, or the whole cereal. 

Veal-broth. — Made as above, substituting veal. Useful 
in constipation. 

Chicken-broth. — To every pound of chicken add i quart 
of water. Proceed as under mutton-broth. A useful sick- 
room delicacy, alone or in combination as above. 

10 



146 ARTIFICIAL FEEDING. 

Squab-broth. — To one freshly killed and thoroughly 
cleaned and washed squab, add sufficient water toi cover, 
and a handful oif washed celery tops. Boil fromi twenty 
minutes to one-half hour. Strain. Cooil. Remove fat. 
Salt. An excellent stimulant to the appetite. Useful as a 
change. May be used plain or in combination with cereals, 
especially well-cooked rice. 

Vegetable-broth. — Ihoroughly wash i beet, i carrot, a 
handful of spinach, and some celery tops. Add i quart of 
water. Boil until vegetables are tender. Strain. Add 
sufficient boiled water to make a quart. Salt toi taste. Use- 
ful as a laxative, antacid, antiscorbutic, antirachitic, or 
antiexudative. 

Creamed Broths. — Any of the broths above detailed may 
be creamed or thickened. Rub i medium-sized tablespoon- 
ful of wheat-flour into a smooth paste with a cupful of the 
cold broth. Add remaining portion of the quart. Bring 
toi boiling point with constant stirring. Cool. Salt toi taste. 
Warm before using. This adds toi the bulk and nourish- 
mient Oif the broth and assists in its constipating e:ffect. 

Burnt-flour Soup. — Brown i tablespoonful of wheat- 
flour in a clean pan, with or without butter. Add.i quart of 
water and bring slowly toi boiling point withi constant 
stirring. Salt to^ taste. Very useful in diarrhea in older 
children. Fed cool or warm. 

Beef -jelly. — To i pound of fresh, lean, chopped beef add 
I pint of water. Boil one hour. Renew water. Strain. 
Salt to taste. Allow to cool, when it jellies. A sickroom 
delicacy. 

Rice. — Wash a cupful of best rice several times with 
warm water. Add sufficient water tO' cover it. Boil three 
hours. Renew water fromi time to time as needed. Strain. 



FOOD RECIPES. 147 

Salt to taste. Rice should be mushy. Taken with milk, 
mutton-broth, butter, salt, meat-juice, or sugar and cinna- 
mon. May be mixed with apple-sauce. 

Cornstarch. — Rub 2 tablespoonfuls of cornstarch intO' a 
smooth paste with milk. Heat what remains of i quart of 
milk. Beat up 2 eggs well. Add the ho't milk, the eggs, 
and 2 ounces of sugar and a little salt, tO' the cornstarch 
paste. Mix well. Bring tO' a boil, stirring constantly. 

Cornmeal-gruel. — One-half cupful of selected yellow 
cornmeal is sprinkled intO' i pint of hot water or hot milk. 
Salt is added. Cook for one hour in a double boiler. 

Arrowroot. — Rub i teaspoonful O'f best arrowroot into a 
smooth paste with little milk. Add ^ pint of boiling milk, 
meanwhile stirring. Cook five minutes without burning. 
Sweeten and salt to taste. It may also' be flavored with 
vanilla or cinnamon, etc. 

Arrowroot-water. — Add, without lumping, i teaspoonful 
O'f arrowroot to i pint of water. Boil one-half hour. Re- 
new water to a pint. Salt to taste. Useful as a drink plain 
or flavored with vanilla or added to milk as a diluent to 
attenuate the curd. 

Cream of Wheat, or Farina. — Made as cornmeal-gruel. 

Stewed Squab. — See squab-broth, page 146. 

Baked Potato. — Wash a large potato clean. Dry. 
Punch full of holes with a fork. Dampen the outside and 
cover with salt. Put in a hot oven in a pan in which 
salt has been placed. Bake quickly. Break open at once. 
Mash and serve with milk, butter, or beef-juice. Salt to 
taste. 

Spinach. — A\'ash spinacli ten times with cold water, re- 
moving all grit and worms. Cover with water to which 
a little salt has been added. Cook until tender. Place in a 



148 ARTIFICIAL FEEDING. 

collander to remove all water. Chop very fine on a clean 
board. Brown a little flour with butter, in a pan. Stir in 
the spinach until hot. A little milk or cream, may be added 
if desired. 

Stewed Celery. — Separate stalks of celery. Thoroughly 
wash. Cut stalks into small pieces. Cover with slightly 
salted water. Stew until tender. Pour off water. Add a 
little plain mlilk or milk to which a little flour has been 
added. Add a small piece of butter, dash of salt and pep- 
per. Heat to boiling. 

Stewed Onions. — Pare young onions of medium size, 
then prepare as celery. 

Coddled Eggs. — Place a fresh egg in boiling water. 
Remove from fire. Allow egg to remain immersed two 
minutes. Open at once. 

Egg-water. — The white of i fresh egg, beaten slightly, 
is added tO' i pint of cool water. Shake well. Strain. 
Salt and sweeten, if desired, to taste. Feed plain or with 
cereal-waters, or beef-juice. 

Toast-water. — Pour i pint of boiling water over i large 
piece of well-browned toast made of stale bread. Stand 
five minutes. Strain. Salt to taste. Useful in diarrhea, 
given cold or hot. 

Lime-water. — Piece of unslacked lime size of a walnut. 
Cover with water and mix well until thoroughly slacked. 
Allow to stand twenty-four hours. Decant. Filter. 

Junket. — Warm i pint of milk, flavored with vanilla., if 
desired, to about ioo° F. Divide into small' glasses or 
cups. Stir quickly into each % teaspoonful of liquid 
rennet or Fairchild's essence of pepsin. If it be desired 
not tO' divide into glasses, the milk, sugar, flavoring, and 
ferment (f5j to f3ij to the pint) may be mixed together 



/ 

FOOD RECIPES. 149 

and the whole heated to ioo° F. in a double boiler. Re- 
move and place on ice as soon as clotting- occurs. 

Baked Apples. — Wash apples well. Core them. Fill 
holes with sugar, and, if desired, a small piece of butter. 
Place in a pan, with a little water. Bake until soft. Serve 
plain or with cream and sugar. A useful dessert. 

Orange-juice. — Slice an orange in half. Remove juice 
b)'' hard pressure or lemon-squeezer. Strain toi remove 
seeds and pulp. Given cold on an empty stomach. Anti- 
scorbutic and laxative. 

Prune-water. — Wash a pound of prunes clean. Cover 
with water. Boil one hour. Renew water oif evaporation. 
Add no sugar. Strain. Laxative, antiscoTbutic. Sugar 
may be added if desired. The prune^pulp is also^ a good 
laxative for older children. 

Acacia-water. — Pour i pint of boiling water over i 
ounce of gum arable and agitate until dissolved. Strain. 
May be used plain, cool, or be flavored with sugar, salt, 
orange- or lemon- juice. A small amount of brandy may 
also be added. Demulcent, febrifuge, thirst quencher. 

Gelatin. — Soak the contents of i small package of 
Knox's gelatin for one hour in just enough water tO' cover 
it. Add I quart of boiling water. Stir until dissolved. 
Pinch of salt. Flavor with sherry wine, vanilla, or fruit- 
juice. Add sugar to the proper degree of sweetness. Set 
away to cool and thicken. A useful, cooling dessert. Has 
no nutritive value, but is filling and satisfying. 

Zweiback may be made by rebaking stale bread or cake,, 
or it may be purchased. It is a useful, easily digestible 
foodstuff, and is slightly laxative. It may be served dry or 
with butter, or, more commonly, with hot water and sugar. 

Holland Rusk may be used as zweiback. 



CHAPTER IV. 
INFANTILE ATROPHY. 

Synonyms. — Marasmus, Essential Marasmus, Decom- 
position, Infantile Wasting, Baby Consumption, Athrepsia. 

Definition. — Marasmus should include only those cases 
of gradual but progressive loss of weight which depend 
upon the faulty assimilation of a food, faulty for the in- 
dividual and admiinistered over a comparatively prolonged 
period of time. All other instances of wasting occurring in 
infants are symptomatic of more or less tangible causes. 

PATHOLOGY. 

In essential or dietetic marasmus there are neither gross 
nor microscopic demonstrable lesions which account for the 
symptoms. A further discussion as tO' the findings in a case 
dead from this disease Avould be time consuming and of no 
practical value. Those cases which exhibit tuberculosis, 
S3^philis, chronic suppuration, acute sepsis of the newborn, 
obstructive pyloric disease or chronic meningitis, are not 
essential marasmus, but simply instances of wasting which 
are dependent upon any one of the factors aforementioned. 

ETIOLOGY. 

Predisposing Causes. — ^Improper artificial feeding is re- 
sponsible for the majority of cases. It usually follows the 
causeless withdrawal of the breast. Marasmus is -rarely, if 
ever, met in the breast-fed. Personally I have never seen a 
case. Diarrheal diseases in the artificially reared, especially 
in those cases encountered in the summer months, often are 
(150) 



ETIOLOGY. 151 

responsible for such an impaired nutritional state that the 
degree O'f food tolerance does not again extend beyond the 
minimum quantity, or at least does not reach the optimum 
amount necessary to sustain life and to proivide for gain. 
Many of these cases develop marasmus because the func- 
tional activity of the glands of the gastrointestinal tract has 
been so perverted that no food could subsequently be found 
which could again properly activate them to produce normal 
ferments. Hence normal digestion could not occur and 
assimilation of improper end-products was the final result. 
Recovery cannot ensue unless the proper food is found to 
normally activate these perverted glands. 

Poverty and improper hygienic surroundings, vitiated 
atmoisphere, personal neglect, and overcrowding are predis- 
posing factors of prime importance, especially when com- 
bined with improper and irregular nourishment. Infants 
upon the breast will stand a wo'nderful amount of abuse 
and neglect. Remarkable specimens of babyhood are fre- 
quently encountered in the slums. These .infants thrive in 
spite of filth and poverty, retaining in many instances the 
one human heritage of which a perverted and selfish social 
system cannot rob themi — the milk from their mothers' 
breasts. 

Complete the theft — deprive these poverty-stricken 
babies of human milk — and the joined forces of artificial 
feeding and squalor will produce numberless cases of 
marasmus and fill many unnecessary graves — permanent 
monuments of disgrace toi our present-day, much-vaunted, 
but barbaric civilization ! It is not, howe\^er, to be assumed 
that marasmus is not met among the rich. Here idleness, 
indolence, indifference, hysteria, selfishness, and ignorance, 
as surprising as it is common, deprive many an infant of the 



152 INFANTILE ATROPHY. 

better class, so^ called, of its rightful heritage O'f breast 
feeding. 

The baneful results of overcrowding and of artificial 
feeding are nowhere better illustrated than in hospitals for 
infants. These babies doi not receive a sufficient comple- 
ment of fresh air. It is an impossibility for a nurse in 
charge of five or six babies, however willing she may be, to 
attend promptly to the personal and physical wants of her 
charges. Many of these babies do not receive their food 
properly warmed or the bottle is not held for them, and con- 
sequently the food becomes cold or the infant falls asleep 
with the meal unfinished, and the fact is not discovered until 
the time for the next feed arrives. The attending physi- 
cian either can not or does not study carefully the individual 
nutritional demands or the peculiar digestive capacities of 
his charges. In a word, these babies lack mothering and 
detailed care, and they cease tO' gain. They lose, and 
speedily there is developed marasmus. 

Ignorance as .to the adaptability of the individual diges- 
tive appiaratus to the various food elements may, on the 
part of the would-be dietitian, lead to serious digestive dis- 
orders which will eventuate in a perverted metabolism and 
marasmus. Thus, one infant may exhibit protein intoler- 
ance, another will be disturbed by fat, and yet another by 
sugar. Starch, fed in excess or over a prolonged period or 
exhibited without the additional food elements (protein, 
fat, sugar), may lead to such injury of the gastrodntestinal 
mucosa as to prevent the proper assimilation of food. This 
is especially noted after summer diarrhea, where patients 
are for long periods kept upon cereal- waters (barley, rice, 
oatmeal) without the addition of milk (Mehlnahrschadeu: — 
Czerny and Keller) . Scrutiny of the stools and the charac- 



ETIOLOGY. 153 

ter of the symptomatology presented by the digestive organs 
will enable the practitioner to decide, in most instances, upon 
the mischief-making factor. (See Chapter II, page 104.) 

Age in itself has no direct influence on the incidence of 
this disease, although most cases begin under i year. After 
dentition has proceeded tO' the appearance of five or six 
teeth the possibility of marasmus, unless unusual circum- 
stances obtain, is extremely rare. Sex and race have no 
influence. Prematurity, usually associated v^ith an unde- 
veloped gastrointestinal mucosa and a deficient glandular 
system, leads tO' digestive difliculties, at times insurmount- 
able, and upon these depends the development of marasmus. 

Exciting Cause. — ^This is at present unknown. Many 
theories have been advanced, but none has received imiver- 
sal acceptance. The depressed nutritional state and dimin- 
ished food tolerance probably result from a perverted body 
chemistry — a disturbed metabolism wherein the calories can- 
not be supplied to the individual in a digestible form so as 
to provide for growth as well as toi maintain body tempera- 
ture and tissue balance. Hence downtear exceeds upbuild, 
and the individual commences to feed upon his own stored 
tissues to' furnish sufficient calories tO' sustain life. This 
perverted metabolism* may be produced by an initially per- 
verted activation of the salivary glands by a food improper 
for the individual. Thus results successively perverted 
activation of all the glands of the gastrointestinal tract. 
This idea may be amplified as follows : — 

When the adult sees, thinks of, or tastes wholesome food, 
the functional activity of the salivary glands is inaugurated. 
This phenomenon, commonly known as "mouth watering," 
occurs as the result of stimulation of the nen^ous mechan- 
ism of the glands as the result of psychic or physical impulses 



154 INFANTILE ATROPHY. 

transmitted through the sympathetic or sensory system,. It 
may be assumed that this normal stimulation results in the 
elaboration of a saliva noirmal in every respect and capable 
of acting normally upon a nornnal food. The food thus 
prepared is swallowed. As the result of normal salivary 
digestion upion normal food, end-products, themiselves nor- 
mal in every respect, are formed. The entrance of these 
noirmal end-products into the stomach is responsible in turn 
for the normal activation of the glands of the gastric mucosa. 
These therefoire produce a gastric secretion also nornnal. 
This, acting upon the partially digested food, and end-prod- 
ucts of the salivary digestion, converts the whole into still 
further normal end-products characteristic of this stage of 
the digestive process. These, entering the duodenum:, nor- 
mally activate the pancreas and the liver, causing' these 
glands to elaborate their secretions in no, way perverted. 
These now continue their normal action upon the remaining 
food and end-products normal to this stage of digestion. The' 
final whole now enters the intestines, the glands, of which 
are normially stimulated likewise to produce a normal secre- 
tion which, again acting upon normal end-products, finally 
completes the process of digestion by the conversion of all 
remaining food and normal end-products into normal final 
products, which, absorbed by the normal intestinal mucosa, 
eventually reach the blood and tissues via liver and thoracic 
duct, and these, being normal in every way, not only pro'- 
vide for tissue upbuild and downtear, but for growth as 
well. 

Now let us consider the reverse. The mere sight or 
smell, not alone the taste, of abnormal or unwholesome food 
(abnoirmal or unwholesome for the individual), not only 
perverts the salivary secretion, causing an inhibition, but 



II 



/ . 

ETIOLOGY. 155 

may even cause serious g-astric and intestinal disturbances 
resulting- at times in vomiting and diarrhea. In other words, 
if we substitute the word unwholesome for wholesome and 
abnormal for normal in the statements of the preceding 
paragraph, we may assume an hypothesis not at all unlikely 
in its applicability to the etiology of infantile atrophy. 
Primary abnormal stimulation by an unwholesome food 
produces the initial abnormal secretion and resulting abnor- 
mal end-product which, acting upon the whole line of gastric 
and intestinal glands, are the essential factors causing the 
production of abnormal secretions and end-products at each 
stage of the digestive process. Each abnormal end-product 
is responsible for the initiation of the abnormal glandular 
activation in each step following. The final product, when 
the end of the digestive process is reached, is abnormal for 
the individual — does not nourish him, i.e., not only is down- 
tear and upbuild not secured, but growth is not inaugurated. 
Therefore the individual feeds upon his own tissues, loss 
ensues — atrophy, malnutrition, marasmus — decomposition 
becomes apparent. 

That this is theory cannot be combated. That it may be 
sustained by clinical facts and circtimstantial data is also 
true. One common clinical experience is sufficient tO' war- 
rant its consideration. These cases of" atrophy present 
neither a gross nor a microscopic anatomy as stated. No 
perverted or diseased state of the gastrointestinal mucosa is 
discernible. Therefore the productive element must reside 
in the food itself. In fact, it must be the food itself ! This 
is substantiated by many cases which have run the gamut of 
formulas, food mixtures, and a score of physicians and pedi- 
atrists, reduced to actual skin and bone, are commonly re- 
vived by the substitution of proper food (proper for the 



156 INFANTILE ATROPHY. 

individual). In the majority of instances this food is breast 
milk or a fortunately thought-out miilk adaptation. In 
other words, the cause and cure oif the condition have been 
determined on the instant from which the infant commences 
to thrive' — the proper food has been substituted to" produce 
normal activation of the salivary glands initially, from which 
will follow in succession normal activation of the stomach, 
the pancreas, liver, and intestines. The end-product is cor- 
rect and upbuild exceeds downtear. The tide is turned and 
the infant thrives. In other zuords, the etiology of infant 




Fig. 26. — Essential marasmus. 

atrophy is the continuous use of a food faulty for the indi- 
vidual, and its successful therapy consists in finding the 
proper food for the individual — a responsibility often more 
readily stated than accomplished, and yet withal, the con- 
ditio sine qua non. 

SYMPTOMS. 

The clinical picture of infantile marasmus is typical and, 
when once seen, is indelibly impressed upon the memory. 
It must be remembered, however, that other conditions will 
bring* about a state of wasting identical in all appearances 
tO' that which we now understand as essential dietetic maras- 
mus. These infants (Figs. 26, 27, and 28) appear' senile. 



SYMPTOMS. 



157 



weazened, and shrunken. The entire face, including the 
forehead, is wrinkled. The wrinkles are intensified by crying 
and surrounding the mouth they assume the form of a 
parenthesis. The features are pointed. The cheek-bones 
are prominent. The eyes commonly appear large and 
bright. There is an absence of fat in the orbit. This causes 
the eyeballs to recede. Later the eyes may be cornered by 
a thick scum of mucus. The tongue is often clean and pre- 
sents a bright-red surface with swollen papillae. It may be 




Fis-. 



-Essential marasmus. 



covered with milk-curds, or thrush. The buccal mucosa is 
pale. The sucking pads remain after every other vestige of 
subcutaneoiis fat is lost. The skin hangs in folds upon the 
armis and legs, especially at the axillae and oo the inner 
aspects of the thighs. The skin may be muddy and dark, 
or may be unusually transparent. The skin over the but- 
tocks may be intact, but is often excoriated. These infants 
move their arms and legs slowly, sometimes appearing to do 
so with deliberation. On the other hand, they may lie 
quietly in their cribs, unless disturbed. In the beginning 
the cry is strong. Later it becomes whiny and, in fatal 
cases, just preceding dissolution, it may be hoarse and 
weak. The skin of the abdomen is loose and may be 



158 



INFANTILE ATROPHY. 



readily wrinkled when gathered between the thumb and 
forefinger, on account of the loss of subcutaneous fat. The 
belly is often distended. If these infants are laid naked upon 
their backs and their legs extended, they give the appearance 
of a frog — wide abdomen, narrow hips, and skinny legs 
(Fig. 29). 

The temperature is subnormal. This is an important 
diagnostic point. The pulse is normal. It may become weak 
and rapid. 




Fig, 28. — Marasmus. Characteristic attitude and appearance. Poor 
circulation shown by cyanosis of feet. 



Vomiting is a rare symptom. It is not an essential feat- 
ure of the nosology of marasmus. It may result from an 
acute digestive disturbance or indicate the effect of a tangible 
etiologic factor, viz., excessive fat oir sugar feeding (exces- 
sive for the individual). The bowels move from once to 
five times a day. The movements usually appear well 
digested. Often they are green and contain mucus and 
curds. This follows a dietary indiscretion. If fat has been 
fed in excess, they are greasy. The fat is recognized by its 
response to its various tests (Chapter I, page 33). The 
movements may be constipated and greasy, loose and greasy, 



SYMPTOMS. 



159 




Fig. 29. — Frog appearance in essential marasmus. Note the wide 
and prominent belly, the narrow hips and skinny legs. This descrip- 
tion is original with the author and has been of material assistance to 
him in teaching. 



160 INFANTILE ATROPHY. 

hard and friable, or may contain soap (Plate VII). If the 
curds be protein they respond readily to the tests for this 
substance (Chapter I). The stool is neutral or alkaline. 
Where excessive quantities of sugar are fed, the movements 
are watery and usually acid and excoriate the anal region. 

The urine in most cases is normal. It may be concen- 
trated and deposit urates and uric acid upon the diaper. In 
some constipated cases receiving too much fat it is ammoni- 
acal. 

The blood exhibits the evidences of a symptomatic ane- 
mia, and may appear unduly concentrated, the clotting time 
being shortened. 

These babies often have a voracious appetite, sucking 
vigorously upon whatever is placed within their mouths. 
They frequently suck constantly upon the hand until the 
fingers become macerated and sore (Fig. 27). The stomach 
is dilated and may present undue motility. The heart and 
lungs present no abnormalities. 

Where excessive starch (for the individual) causes the 
injury to the gastrointestinal mucosa (see Etiology, page 
152), a peculiar type of atrophic infant is presented. The 
muscles are hypertonic. The tissues are dry and atrophied. 
The bowels are loose, the abdomen is distended, and 
anemia is marked. The etiologic factor, as providedi by a 
history of prolonged starch feeding, m.us;t in this instance 
be known in order to conclude a proper diagnosis and to 
provide a proper therapy, viz., the exhibition of breast milk 
or of properly adapted cows' milk, and the exclusion of 
starch, at least for the time being. It must be remembered, 
however, that there are cases wherein an excessive starch 
diet is associated with an unusual increase in weight, due to 
the retention of water in the system. These babies are fat, 



SYMPTOMS. 



161 



doughy, and present a tendency to secondary infection, 
corneal ulceration, bronchopneumonia, and skin lesions. 
Edema, unassociated with nephritis, is not uncommon, and 
depends upon hydremia (Fig. 30). If starch is withdrawn 
and milk added to the feeds, these infants lose weight. In 
the iirst instance, however, the loss is only temporary. A 
second and permanent gain is inaugurated finally when the 
gastrointestinal mucosa assumes its normal state. Those 




Fig. 30. — Marasmus complicated by edema. Note the pits from 
pressure on the lower leg and thigh and also the edema of the de- 
pendent portion of the abdomen and of the face. 



cases which present corneal ulcerations are frequently fatal 
(Czemy). 

In yet another type, where atrophy is associated 
with hypertonicity, the physical appearance is not unlike 
that of tetany. The muscles are rigid and boardlike and the 
electrical excitability is materially increased. The head is 
often retracted. The stools frequently respond to the 
starch test with iodine. 

The zveight curve exhibits a gradual depression in all 
cases of miarasmus. From 5 to 6 ounces per week is the 



162 INFANTILE ATROPHY. 

usual record of loss. At times there may be a week or two 
when the weight does not fall, but remains stationary, or 
there may be a gain of an ounce or two. Sudden losses 
are not common unless there occurs an attack of diarrhea 
or some other complication. Where edema is present, espe- 
cially in moribund cases, a sudden rise in weight miay be 
recorded. This should always be borne in mind, soi that the 
mistake may not be made of regarding it as a turn for the 
better. In cases which do not recover, the loss in weight 
usually proceeds to the point where the infant averages be- 
tw^een 6 and 7 pounds. It is also noted in some cases that 
when once the proper food is found, or a change is made 
from one formula to another, a rapid gain of fronii 6 toi 10 
ounces may be recorded within forty-eight or seventy-two 
hours. The infant shows marked evidences of improve- 
ment in every way. After a week or twO', however, the 
usual gain is from 3 tO' 8 ounces per week. 

COMPLICATIONS. 

Sudden and unexpected death may occur in these little 
babies when their condition seems toi be no' worse than it had 
been for some weeks previously. The spark of life has been 
fluttering for< some time when, unexpectedly but quietly, 
the supply of fuel having been exhausted, without struggle, 
it gradually ceases tO' burn and life is extinct. This fre- 
quently happens during the night, and the infant is found 
dead in bed in the morning. Hypostatic pneumonia may 
develop as a terminal evidence of feeble circulation and of 
lying in the prone position for a long time. These infants 
are susceptible to cold, chilling of the surface, and to sudden 
changes in temperature. Hence colds, rhinitis, bronchitis, 
and bronchopneumonia occur. All are poorly borne and 



/ ^ 

COMPLICATIONS. 1(53 

frajuently determine a fatal outcome. Purpura, affecting 
the skin of the lower thorax and al^domen, and appearing as 
a thickly scattered, fine eruption, occurs from twO' to three 
weeks before death, in many cases. I have never seen a re- 
covery in which this symptom appeared. Should these 
cases develop an acute diarrheal condition, accompanied by 
severe straining, inguinal hernia may appear. In one case 
under my care, strangulation of a hernia occurred, and 
was successfully operated upon by Dr. Stillwell C. Burns. 
Frcxm the same cause prolapsus ani develops, and may be a 
troublesome though usually not a dangerous issue. Anal 
excoriation and severe irritation of the entire buttock may 
seriously incommode the infant and interfere with its quiet. 
Stomatitis and thrush are usually directly dependent upon 
faulty technique in the antiseptic toilet of the mouth. Der- 
mal irritations of all varieties, bed-sores, macerations, inter- 
trigo, furunculosis, acute dermatitis and erysipelas are 
avoidable, troublesome and sometimes dangerous occur- 
rences in pooirly kept cases. Edema occurs without nephritis 
and is an exceptionally interesting phenomenon, since its 
etiology is obscure (Fig. 30). It has been already re- 
ferred toi as being responsible for a sudden increase in the 
weight. It appears first in the extremities and is a terminal 
state. It spreads upward and may involve the abdominal 
wall or the entire body. The temperature is very much 
below normal and the urine is clear, limpid, and free of 
casts and albumin. Its supposed association with injury 
of the intestinal mucosa by starch (Mehlnarschaden) has 
been previously noted. Its dependence upon the retention 
of fluid within the tissues, on account of the presence of 
sugar and salt in them, has been maintained by some 
authors. Although in most instances indicating a fatal 



164 INFANTILE ATROPHY. 

outcome, I have seen this symptom, contrary to- the fore- 
going" view, entirely disappear following the daily injection, 
subcutaneously, of warm normal-salt solution. Sclerema 
and scleroderma may occur as prelethal conditions. Scurvy 
and rickets may be met as the result of carelessness in feed- 
ing proprietary foods or boiled preparations over too long a 
period of time without taking proper precautions. 

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 

This must be made entirely by the exclusion of all other 
causes of wasting. There is usually a history of the 
groundless discontinuance of the breast, and the feeding in 
rapid succession of various milk formulas and a host of 
proprietary foods, some of which may agree and cause a 
temporary gain in weight. The mere presence of wasting 
does not, as we now understand it, necessarily mean 
marasmus. In my experience, the most common error in 
this connection is tO' regard wasting dependent upon hid- 
den chronic suppuration and wasting dependent upon 
pyloric obstruction as maras-mus. As an instance of the 
first circumstance there appeared at my clinic at the 
Lebanon Hospital, some years ago, an infant i6 months of 
age, wasted to skin and bone, in whom the diagnosis of 
marasmus had been made. The age of the child — 16 
months^ — and the presence of teeth led tO' the thought that 
some factor other than a dietetic error was operative. 
Fever and leucocytosis were absent. A careful physical 
examination led to the diagnosis of encysted empyema, 
which was verified by exploratory puncture. Operation was 
followed by complete recovery within three months. In 
this case the absence of fever and of leucocytosis, and also 
of a careful examination, in all probability caused the 



DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 165 

empyema to be igniorecl. The two former were absent no 
doubt on account of the fact that the infant's strength and 
resisting power had been so vitally reduced that neither the 
heat centres nor the leucocytes could any longer be stimu- 
lated by the toxins of the invading organisms; or the sys- 
tem had become immune to this particular bacterium, for 
the co-ndition had in all probability lasted for months. The 
age of the child, presence of teeth, and the previous history 
of a pneumonia should have led toi a careful physical ex- 
amination, if to nothing else. 

I have seen wasting due to^ other forms of chronic sup- 
puration — double otitis media of long standing, chronic 
mastoid disease, pulmonary abscess — diagnosed as simple 
marasmus and treated by formula. In one instance, in which 
death' ensued, a fatal issue could have been avoided if the 
importance of the primary underlying factors had been 
appreciated. The mere mention of these facts should be 
sufficient to prevent the careful practitoner from falling into 
error. 

I have seen 24 or more cases of pyloric obstruction of one 
type or another, and in each instance save 2 was the diag- 
nosis of marasmus made. This is a grievous error, since 
non-surgical or surgical treatment will save the majority 
of these cases if they are promptly recoignized. In maras- 
mus, vomiting is rare. In pyloric obstructive disease, it is 
a prominent and early feature, propulsive in character, and 
occurring without apparent cause. It is especially sugges- 
tive in breast-fed babies, occurring immediately or a few 
wrecks after birth. This vomiting is usually responsible for 
taking these babies from the breasts, and this fact in itself 
should always arouse suspicion. In pyloric disease, inquiry 
w^ill determine that the bowel movements are constipated. 



166 INFANTILE ATROPHY. 

exceediriig-ly small, infrequent, or entirely absent. Visible 
gastric peristaltic waves are present. The pylorus is fre- 
quently palpable. The administration of lo grains oi char- 
coal is followed by its delayed or non-appearance in the 
anal discharges and its recovery in the water following 
stomach wasting twenty-four hours later. The X-ray gives 
valuable information not only as to the presence of obstruc- 
tion, but also as tO' the degree of patency of the pyloric 
orifice, although this examination is not essential tO' an 
accurate clinical diagnosis. In conclusion it may be stated 
that the only symptoms which pyloric disease has in co^m- 
mon with marasmus are the progressive wasting and the 
subnormal temperature. 

Tuberculosis may be a cause for wasting. The term' 
^'babies' consumption" may, with propriety, be applied to 
this condition, but not to^ ''marasmus." Both terms are 
regarded by many of the laity as synonymous and, conse- 
quently, this idea is responsible not only for much con- 
fusion, but also for much unnecessary fear. Tuberculoisis 
will be discovered by careful investigation of the lungs, 
glands, and bones in particular. Fever is a common possi- 
bility, but may be absent. A careful rontgenographic ex- 
amination of the bronchial nodes may determine these tO' be 
tubercular and a cause for the wasting. The abdomen 
should also, be thoroughly palpated for enlargements, and 
the result of a carefully performed von Pirquet or Moro 
test should not be ignored in coming toi a correct conclusion. 

Syphilis, without skin lesions, especially in the very 
young, causes not a few infants toi rapidly shrivel and in 
outward aspect they closely resemble marasmus. At pres- 
ent the Wassermann test is of much value in detecting these 
cases. In other instances, where this cannot be made, re- 



DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 167 

liance must be placed upon the history of frequent miscar- 
riages, lesions upon the mother or father or both, or the 
appearance upon the infant of copper-colored eruptions, 
mucous patches around' the anus or in the mouth, or of 
rhagades (cracks) about the corners of the moiith, and a 
chronic nasal discharge (snuffles), together with the com- 
mon enlargement of one or both epitrochlear glands. 

Acute but sluggish sepsis of the newborn, manifesting 
itself by slowly forming metastatic abscess — e.g., infection 




Fig. 31. — Atrophy or marasmus due to chronic cerebrospinal 
meningitis. 

of the umbilical stump, retroumbilical abscess, peritonitis in 
the newborn following navel infection — is often associated 
with a shrivelling up process that gives to the infant a dis- 
tinctly marantic appearance. 

Cases of cerebrospinal meningitis (Fig. 31) frequently 
pass into a state of extreme emaciation when they do not 
succumb in the acute stage. This is especially true of 
basilar meningitis. Of course, in children beyond the stage 
of infancy the distinction from marasmus need not be made. 
In fact, if one bears in mind the history of the case, even in 
the very young, a mistake is hardly likely to occur, and the 
condition is mentioned merely tO' make the list of possibili- 
ties complete. 



168 INFANTILE ATROPHY. 

Finally it must be stated that malignant disease oi any 
form, affecting the young will be recognized by the pres- 
ence of a growth, and the emphasis of local symptoms will 
direct the attention to the seat of the trouble. 

PROGNOSIS. 

Many cases of marasmus recover completely, no vestige 
of the disease remaining in after-life. No case of maras- 
mus should be regarded as hopeless until it is dead. Many 
marvellous transformations are wrought if the proper food 
can be quickly found. It may be said that the prognosis 
depends entirely upon the ease and facility with which the 
practitioner is able to adjust the food tO' the digestive 
capacity and to the nutritional demands of the individual. 
This responsibility is not always discharged without diffi- 
culty. 

Favorable signs are: a speedy change in the stools 
for the better, if they have been abnormal ; a small but ap- 
preciable gain in weight; a rise in temperature to normal 
or to a few tenths of a degree above this point. Unfavor- 
able signs are: frequent digestive disturbances, vomiting, 
diarrhea; a persistence of the subnormal temperature; sta- 
tionary weight or a loss in weig'ht, and the appearance of 
edema or purpura. Complications, however trivial, espe- 
cially respirator}^ or infectious, are badly borne. Speaking 
generally, it can be stated that the nearer the age approaches 
a year and the shorter the duration of the condition, the 
better is the prognosis. Environmental conditions and 
attention to details also materially influence the outcome in 
individual cases. The results of treatment in private cases 
are therefore better than in institutions. 



TREATMENT. 169 

TREATMENT. 

Preventive. — Disease will largely disappear when pov- 
erty and ignorance are no more ! The incidence of maras- 
mus will sliare in this general decadence of misery when 
society ceases to rob man of his right to toil and to share 
justly in the products of his labor, and no longer denies to 
his offspring the right to suck its mother's breast. So too, 
when physicians and mothers cease to advance their arti- 
ficial and false ideas as to the feeding of infants, and dis- 
continue to condemn without reason the human milk- 
supply in individual cases, and when manufacturers of 
patented foods cease in their efiforts to dictate tOi physicians 
how to feed the infants of the land, the cases of marasmus 
will disappear. Baby-saving shows, mothers' clubs, neigh- 
borhood talks by competent nurses and physicians, and 
educational propaganda O'f every variety should be en- 
couraged to instruct the motherhood of the country as to 
the necessity of conserving the human milk-supply, and as 
to the means of accomplishing it. Hospitalism should stop. 
The moment an infant has recovered from an acute infec- 
tion, if this be the cause of its presence in the hospital, it 
should be removed therefrom to its home or to the country, 
and to its mother's breast. I am in full accord with the 
teachings of Henry Dwight Chapin on this point. If pos- 
sible, during its stay in the hospital it should be nursed by 
its mother. When for a sufficient reason an infant is de- 
prived of its mother's milk, every means should be exerted 
to provide it with clean cows' milk so adapted as to meet 
its digestive capabilities, and to provide it with sufficient 
calories to meet its nutritional requirements. 

Active Treatment. — Marasmus should not, if possible, 
be treated in a hospital. From the preceding it may be cor- 



170 INFANTILE ATROPHY. 



rectly inferred that the mortaHty in institutions is higher 
than in private practice. Especially if the infant be under 
6 months of age, every effort should be made tO' secure 
breast feeding. If its mother's milk is not available the 
milk of another woman should be provided. This is not 
always possible, however, among the poor, unless a volun- 
teer be secured. If one woman does not supply sufficient 
milk, the milk of many healthy women, if obtainable, may 
be mixed together and fed whole or diluted by dropper or 
bottle. If all breast-milk feeding cannot be had, if it be at 
all possible, one o^r more feeds of human milk should be 
given in twenty-fofur hours. A case recently seen with Dr. 
J. Cohen illustrated the almost specific effect of breast milk. 
The marantic infant, 4 months of age, was one of twins. 
The patient was receiving cows' milk, diluted, and the other 
twin was upon the breast. This baby was fat and healthy ; 
the other was in a dying condition. It was placed upon the 
breast and the healthy infant, having had a good start, was 
put upon carefully adapted cows' milk. The sick infant 
made a complete and brilliant recovery and the healthy in- 
fant was not harmed by the change. Among the well-to-do, 
wet-nurses, carefully examined, may be secured at various 
prices. Their services are often invaluable in turning the 
tide toward recovery. Even though the wet-nurse's milk is 
excellent, it must be stated that the employment of these 
women does not always bring peace and contentment into 
the home. On the contrary, the practice of wet-nursing is 
far different from the theory. Temperamental differences 
between the wet-nurse and the moither, together with house- 
hold and domestic problems, often bring disaster tO' the 
arrangements when everything seems serene. 

Good results, too, may be secured by artificial feeding. 



TREATMENT. 171 

Every effort should be made to study thoroughly the pecul- 
iarities of the individual infant, and to determine the food 
element or elements which may be the causative factor or 
factors. The essential thing is to individualize, and not to 
treat infants by the same routine or by one method or sys- 
tem of feeding. Another essential is to^ secure clean milk 
and to keep it clean. With this in view, careful attention 
should be given to nipples and bottles, proper refrigeration, 
amount toi be fed, feeding interval, the time consumed in 
taking the meal, and to the use only of sterile diluents. As 
a general procedure I do not favor the recent fad of long- 
interval feeding, for the reason that my experience with the 
older method of every two hours up to 3 months, with 
from one to two feedings during the night; every two and 
one-half hours up to 6 months, and one or no feeding dur- 
ing- the night ; every three hours up tO' 9 months and every 
three and one-half hours after this time has demonstrated 
satisfactory results to. me. I see no reason tO' change unless, 
in individual cases, where vomiting might be benefited by a 
prolongation of the interval. During the day an infant 
should be fed by the clock. It should be awakened for its 
food, the feeding interval being co'unted from the time it 
started its meal, not from the time at which it finished it. 
During the night it should not be disturbed at all for food 
unless it be very weak. The meal should not be given 
hurriedly — at least from fifteen to^ thirty minutes being con- 
sumed, depending upon the amount fed. The nipple should 
be removed from the mouth at the end of every third or 
fourth suck. The food should be kept warm and the bottle 
should be held for the baby, and it should not be permitted 
to sleep while being fed. The habit of regularity will soon 
be formed, and the little patient will regularly awaken for 



172 INFANTILE ATROPHY. 

its meal. The quantity fed varies as the appetite, the toler- 
ance, and the digestive capacity. Some cases do^ well on 
small amounts frequently administered. This ia true of 
cases which vomit, especially where the longer-interval 
feeding fails. Roughly, the quantity may be regulated 
according to the rules given in Chapter II, page 102. 

It is well to calculate the caloric value of the daily quan- 
tity of food, for in this way we may knoiw whether we are 
feeding above or below the food optimum^ Thus may we 
in a sense prognosticate as to whether or not the food toler- 
ance permits of the administration of sufficient calories. 
Not infrequently, in very wasted infants, a larger number 
of calories are required tO' secure a gain in weight than the 
somewhat arbitrary standard would indicate. (See Chap^ 
ter II, page 82.) 

Cases which exhibit protein intolerance may be handled 
in several ways. At the outset I wish to^ make it plain that 
my experience does not permit me to subscribe to the 
German view, that unmodified cows' curd is not only never 
harmful, but can be fed in almost incalculable amounts. I 
believe that mechanically divided cows' curd, or curd that 
has previously been pre digested or, both, is not only harm- 
less in individual cases, but of great value. 

The coagulahle protein may be entirely eliminated by 
the use of zi;hey. With this method I have had little experi- 
ence, and therefore can neither condemn nor praise it. It 
has never appealed to me, although some autho^rs recom- 
mend its use and report very good results. It cannot be 
continued as a permanent food, as it is lacking in con- 
structive elements. As soon as improvement is noted, addi- 
tions of cream, from ^ to i dram at a time, should grad- 
ually be made. As tolerance is noted these quantities may 



TREATMENT. 173 

be increased. Instead of cream, slowly increasing amounts 
of whole milk may be added. It must be remembered that 
cream is but superfatted milk, and that wkey contains some 
of the ferment which was used in its making. There- 
fore, unless the whey is previously heated to^ 150° F. 
to kill the femient, either the cream or the milk will become 
coagulated. This may not cause any inconvenience as far 
as the infant is concerned, but may alarm the mother or 
the nurse, or the curds may not pass readily through the 
nipple. The whey must not, however, be heated above this 
or the lactalbumin will become coagulated. As soon as 
gain is inaugurated or it is seen that the whey-and-cream or 
the zuhey-and-mdlk mixture is toderated, a gradual change 
should be made to dilutions of milk. These should be weak 
at first and later strengthened. 

In selected cases I have had success with Ramogen 
manufactured by Prof. Biedert (Chapter III, page 129). It 
has been employed as a temporary food, and in some in- 
stances the results have been nothing short of brilliant. 
This is likewise true of Somatose milk, which resembles 
Ramogen, and alsoi of condensed milk in selected cases of 
protein and fat intolerance. All of these preparations, how- 
ever, are but temporary foods and must be safeguarded by 
antirachitic and antiscorbutic remedies as fruit- and animal- 
juices. 

The character of the coagulable protein may be changed 
by simple boiling of milk, whole or diluted. The experi- 
mental ^^^ork of Brennerman^ and of Ibrahim seems to 
prove that the action of the gastric juice upon boiled milk 
is toi cause the formation of curds distinctly softer and finer 
and more closely resembling those of human milk than the 

1 Journal A. M. A. 



174 INFANTILE ATROPHY. 

curd which is formed as the resuh of the action of the gas- 
tric juice upon uncooked milk. In most cases, however, the 
simple boiling of the milk, without other means of modifica- 
tion, in cases of cow-curd intolerance is insufficient to over- 
come the difficulty. In any case, boiling should not be too 
long continued on account of the possibility of scur^^y or, 
if it must be continued over a reasonable length of time, 
fruit-juices and beef-juice should be administered. 

The addition of cereal-waters or gruels made' from 
arrowroot, barley, oatmeal, rice, or wheat-flour, plain, as 
advocated by Jacobi or dextrinized as advocated by H. D. 
Chapin, is an excellent means of causing the curd to become 
comminuted in the stomach and to materially assist in its 
digestion. Where there is a tendency to looseness of the 
bowels arrowroot, barley, rice or wheat may be used, but 
where costiveness predominates oatmeal should be the 
choice. If starch intolerance exists, as manifested by much 
flatulence, dextrinization of these waters or gruels may be 
employed. This is accomplished by the addition of some 
preparation of malt or by the use of Cereo, which is a 
glycerite of diastase and is made by the Cereo Company of 
Tapp^an, N. Y. This Company also manufactures a fine 
grade of cereal flours from which these w^aters or gruels 
may be made, but I have for years employed with satisfac- 
tion the simple grains (Chapter II, page ^y). In cases of 
difficult protein digestion the use of Keller's Malt Soup is 
said to give brilliant results, especially w^here the atrophy is 
associated w^ith an intensely ammoniacal urine. Sooith- 
worth's recent experience with this substance, especially in 
hospital cases, has been extremely encouraging. Malt Soup 
closely resembles the dextrinized gruels as recommended by 
Chapin. Malt Soup preparations made in America by the 



TREATMENT. 175 

Maltine Company are now available. For a number of 
years, in cases where starch intolerance appeared con- 
spicuoiis, I have diluted the completed cereal-water with 50 
per cent, plain boiled water. Where I have wished to 
impress the character of the stools, I have employed these 
waters full strength as the diluent, entirely excluding plain 
water from the formula. 

Sodium citrate will promote protein tolerance in some 
cases, especially where vomiting- is present (Chapter II, 
page 109). 

Of value in many instances is pancreatization. Other 
cases do not do so well upon milk or milk formulas ordi- 
narily pancreatized. Of another form of pancreatization 
and curd modification that has given me much satisfaction 
I will speak presently. The feeding of pancreatized for- 
mulas must not be continued too long, as the digestive ap- 
paratus may be permanently weakened. The food is sub^ 
jected to the action of the ferment for a period of from 
twenty to thirty minutes. If too long continued, excessive 
formation of peptone results and the preparation is made 
bitter. The time of pancreatization is gradually diminished 
and finally omitted (Chapter II, page 108). 

In treating marasmus proper parental intelligence and 
co-operation are as essential as proper food manipulation. 
The necessary means tO' purchase the best milk or access to 
a free milk station are items of no mean importance. Un- 
fortimately ignorance and poverty often prevail, and the 
physician must do the best he can with the means at hand. 
Under these conditions in particular, but also, among the 
well-to-do, where protein intolerance was present, and yet, 
where I felt it was necessary tO' feed protein in rather large 
amounts, I have had most happy results from buttermilk 



176 INFANTILE ATROPHY. 

mixtures. It requires very little intelligence for the mother 
to learn how to make the food. Another consideration of 
prime importance is its cheapness. My method of using 
this preparation is as follows: I first place the baby upon 
the buttermilk-and-flour mixture (Chapter III, page 123), 
omitting the sugar until the movements become normal. 
This is practically an eiweissmilch with the exception that 
"it lacks the curd of an extra litre of milk and it contains 
flour. I now commence to add cane-sugar, running the 
amount up to fifteen and three-fourths teaspoonfuls tO' the 
two^quart mixture. If everything goes well, and usually 
the gain in weight is inaugurated after the addition of the 
sugar, I gradually add cream, first a half-dram toi every 
other bottle, then to every bottle, and gradually increase 
the amount as long as tolerance is maintained. I am forced, 
froiTL my results, to regard buttermilk feeding as an ex- 
ceptionally valuable dietetic measure in marasmus. I have 
learned to depend upon it, as in many instances I ami sure 
that it has saved lives. The mixture is, as before stated, 
easily made, btit directions must be carefully followed. 
This is. particularly true with reference to^ the constant 
stirring of the mixture during the second boiling (if it is 
employed in this manner, which I believe gives better re- 
sults than when the second boiling is omitted), i.e.^ after 
the buttermilk and flour and sugar solutions or the flour 
solution alone have been mixed together. Unless it is 
thoroughly stirred from the minute it is placed] upon a low 
fire, unmanageable lumping will ensue. An infant may be 
kept on buttermilk for months provided antiscorbutic reme- 
dies, as beef -juice and vegetable broth or fruit- juices, are 
administered at suitable intervals. In conjunction codliver 
oil is valuable, especially when adminstered by inunction. 



TREATMENT. 177 

As soon as a substantial gain is recorded (3 to 5 pounds) 
gradual or instantaneous transference may be made to 
properly adapted formulas of whole milk. I cannot recom- 
mend this substance too highly if it be intelligently 
employed. 

Instead of buttermilk and flour without sugar, ekveiss- 
milch answers an admirable purpose in causing the stools 
to become constipated and normal in aspect. Gradually 
carbohydrate, in the form of cane-sugar or Dextri-Maltose, 
isy added. After five to six weeks a prompt return is made 
to whode-milk dilutions. Eiweissmilch may not be con- 
venient and may be difficult to make. The dried prepara- 
tion of eiweissmilch on the market known as Larosan is 
extensively employed by Finkelstein himself, and gives 
good results. Personally I have had a limited experience 
with it. I have observed its use in Finkelstein's clinic in 
Berlin. There I witnessed some good effects in the exuda- 
tive diathesis {vide Chapter XI, page 309) and in maras- 
mus. The stools in diarrhea in which sugar is the active 
etiologic factor are also favorably influenced. 

Asked to name one method of treating marasmus, 
where either protein or fat or both have given trouble, 
which I favor most or rather which has given me the best' 
results, aside from buttermilk, I should unhesitatingly 
recommend the use of some simple milk formula zvherein 
the curd had been modified by the old-fashioned Hour hall, 
with or without the addition of pancreatin, or by the use 
of Benger^s Food, which is flour ball containing pancreatin. 
While this is a proprietary its composition is clearly stated, 
and it is recommended as a milk modifier and not as a food. 
It simply represents an easy way of using flour ball without 
having to go to the trouble of making it. Either one of 

12 



178 INFANTILE ATROPHY. 

these pireparatioos may be added in the amount of from 
2j^ to 5 per cent, of the total quantity of the formula. I 
find the former percentage to answer most purposes. The 
heating to which the milk is subjected alsoi miaterially 
assists in the digestion of the curd. I have never seen a 
case of scurvy developi on account of the heating except in 
one instance where an unruly infant (Plate XI) refused 
to take fruit- or animial- juices. I believe this toi be 
due to the fact that it has not been continued over toiO' 
long a period and because fruit- juices, vegetable broth, 
and meat- juice are always used in conjunction with the 
milk feeding — one of them or all. The miethodi of using 
flour ball or Benger's Food is described in Chapter III. The 
effect of both of these preparations upon the stools is rapid. 
The latter are changed within twenty-four tO' forty-eight 
hours into a light or golden-yellow mass of smooth, mushy 
consistency,' with the characteristic slightly acid, not un- 
pleasant odor of normal breast-miilk stools. This effect is 
continuous. Vomiting is usually checked, although it may 
continue and be without serious significance, and a gain in 
weight is inaugurated. Both the Benger's Food and the 
flour ball, as soon as the indications permit, are gradually 
reduced and finally omitted. The heating, however, is con- 
tinuied for a week or so and then stopped. 

The quantity and quality of the formula are increased as 
the appetite and digestive processes warrant. If constipation 
persists it may be materially lessened by the use of from 
lo to 40 drops of Philip's Milk of Magnesia in each bottle, 
or in every other bottle, or but once daily according to: the 
result obtained. Of late I have been favorably impressed 
by the use of the liquid paraffin preparations (Chapter VIII, 
page 254). 



TREATMENT. 179 

As to the character o»f the formula itself, experience and 
personal equation count for much. This statement is not 
made to sidestep the issue or on account of a desire to deny 
to the practitioner a clear exposition of the details of for- 
mula manipulation, but simply because it is a fact learned 
from large experience. It must, however, be stated as a 
truism that as good results may be obtained by the simple 
dilution of wbole milk or of skimmed milk as with any 
other method. One shoiuld start with a strength o^f about 
one-fourth milk and three-fo'Urths diluent and gradually in- 
crease the quantity oi milk. The key to the entire situation 
is provided by a careful study of the stools^ and the adapta^ 
tion of the strength of the formula to the digestive capacity. 
The method of dilution or of modification is really a matter 
of secondary importance. The physician must simply be 
able tO' increase or diminish the coagulable protein or any 
other of the food elements according to the indication. It 
cannot be too strongly emphasized that success depends 
upon the ability to individualize. 

If the cause of the dig"estive disturbance be fat intoler- 
ance (Chapter II, page no), whey may be employed for a 
short time. It contains a little less than i per cent, of fat. 
To it may be added gradually increasing amounts of 
skimmed milk. 

In other instances signal success has been achieved 
by the use of diluted zvhole milk or diluted skimmed milk. 
In all cases where skimmed milk is employed, it should be 
obtained by skimming the best obtainable whole milk, at 
home, after the cream is permitted to thoroughly rise. As 
tolerance is established one-fourth, one-half, and then 
three-fourths of the cream, which has been removed, may 
be poured back into the jar and the whole w^ell shaken and 



180 INFANTILE ATROPHY. 

then diluted to any strength, or any oif these preparations 
miay be pancreatized or modified by flour ball and pancreatin 
or by Benger's Food. The pancreatin in each instances acts 
upon the fat by reason of the steapsin which it cootains. In 
using pancreatin only the best possible product should be 
employed and pains should be taken tO' see that it is strictly 
fresh. That manufactured by Fairchild Bros, and Foster 
has given mie satisfaction. Buttermilk with flour and sugar 
or eiweissmilch with additional carbohydrates are also 
exceptionally valuable in cases of fat intolerance, especially 
the former, since both are weak in fat. 

If cane-sugar be employed tO' supply the extra carboi- 
hydrate, rarely will any disturbance attributable to» this 
source be demonstrable. Jacobi for years has advocated 
the use of this chemical in preference tO' milk-sugar, and 
my experience bears out the validity of his; teachings. Of 
late, the malt-sugar preparations have come intO' prominence 
by reason of the impetus given them by the German school 
of pediatrists. They owe their popularity tO' the fact that 
they often cause a rapid and permanent increase in weight 
because maltose, which they are all said tO' contain in about 
the proportion oi 50 prer cent., is readily absorbed and rapidly 
assimilated by the tissues. The muscle and body juices 
contain a maltose-splitting ferment, and therefore any mal- 
tose absorbed as such is converted after it leaves the intes^ 
tinal canal and is not again eliminated as maltose. On the 
other hand, lactose and saccharose, when fed in excessive 
amounts, are eliminated in the urine, not being converted in 
the tissues. Maltose is said to be twice as assimilable as 
either of these two. Mead-Johnson's Dextri-Maltose, 
Loeflund's Food Maltose, and Soxhlet's Nahrzucker are 
practically identical in composition. The first is more avail- 



TREATMENT. ^1 

able on account of its comparative cheapness. These prep- 
arations are used in the same strength as either lactose or 
saccharose, being added in the strength of from i to 5 per 
cent. 

If sugar is not borne well at all, buttermilk plain, or 
buttermilk with flour, but without sugar, or eiweissmilch 
furnishes the means of giving nutriment with a minimum of 
this substance. Additional sweetness may be secured by 
adding 1 grain of saccharin to- the quart. Gradually, extra 
carbohydrate is added. Cases which do' not tolerate sugar 
well suffer especially from a subnormal temperature when 
deprived of this elemicnt, and therefore must receive extra 
care by being protected with proper clothing and external 
heat. 

Where the history provides the evidences of starch 
injury, 1. A. Abt^ recommends milk containing a moderate 
amount of fat and the withdrawal of carbohydrate food, 
especially buttermilk mixtures, malt-soup, and cereal de- 
coctions. If possible tO! secure it, breast milk offers 
the greatest chance for recovery. It is administered first 
in small quantities. The primary withdrawal of starch 
may, especially in the hydremic types, cause an initial loss 
in weight. Next to breast milk undiluted cows' milk, at 
first in small and then in gradually increasing amounts, is 
recommiended. Tea or water sweetened with saccharin 
(gr. j to the quart) may be administered to supply fluid. 
Care should be taken not tO' exceed the infant's tolerance 
for fats or, in fact, protein and sugar as well, as it must 
be remembered that the injury produced by the prolonged 
feeding of starch has impaired the tolerance for all the food 
elements. 



2 Journal A. M. A., October 4, 1913, p. 1276. 



182 INFANTILE ATROPHY. 

Food Preparations Other Than Milk. — Useful in the 
treatment of marasmus are beef-juice, freshly made as 
directed on page 145, Chapter III, or Valentine's meat-juice, 
fruit- juices — from oranges, grapes, or prunes stewed with- 
out sugar. Vegetable broths and olive oil are also' useful. 

Meat-juices or fruit-juices are best administered, in small 
amounts, exactly one-half hour before feeding time. This 
permits the juice to enter the stomach after it is empty. 
The previous meal has, under normal conditions, practically 
passed out and entered the duodenum; hence there is nO' 
admixture of meat and milk — a scientific adaptation of the 
Mosaic law which finds modern verification for its originally 
physical, though Biblical, basis. 

Vegetable broth (Chapter III, page 146) is used as a 
drink. It is usually acceptable to the infant. Sometimes it 
is not. It is a valuable antiscorbutic, antirachitic, antiexu- 
dative, antacid, and laxative remedy. Its use, however, 
should not be forced. In fact, this is true of any remedy or 
any food. 

Olive oil in doses of J^ to i fluidram is sometimesi well 
tolerated where the fat of cows' milk cannot be digested. 
It is best given one-half hour after feeding, especially 
where skimmed-milk preparations are used as food. 

Recta! alimentation with small amounts of pancreatized 
milk, and whisky ttIx tO' ""Ixx, administered once or twice 
in twenty-four hours high into the bowel, and previously 
wanned and following a cleansing^ enema, may be useful in 
cases of extreme asthenia as a life-saving agent. 

Hypodennoclysis with normal saline solution, properly 
warmed and administered in amounts varying from 2 to- 5 
ounces and under strictly aseptic conditions, and not oftener 
than once in twenty- fo/ur hours, is a useful remedy (Chap- 



DRUG THERAPY. 183 

ter XIII). This is especially so in those cases of atrophy 
which have followed an attacjk of summer diarrhea (milk 
intoxicatiodi) and in which the onset has l3een rather abrupt. 
The tissues have been speedily dehydrated and demineralized 
by the tremendous loss of water per rectum. 

HYGIENIC MANAGEMENT. 

These babies do better in a warm atmosphere of pure 
air. As before stated, they should not be kept in hospitals. 
If orphans are deserted, they should be placed in hoines, if 
possible, especially if the caretaker can at the same time give 
them the breast. The municipality should thus provide 
home shelter wherever possible for its infant charges rather 
than maintain them in almshouses. 

Regularity in feeding, feeding proper quantities, neither 
too fast nor too sloiw, proper warming of the bottle and 
attention to the minutest detail, which may be included in 
the expression ^'intelligent and wholesO'me care," should be 
provided. 

DRUG THERAPY. 

Drugs occupy a position decidedly subordinate to the 
dietetic and hygienic management of these cases. There 
are no specifics. Extract of thyroid has been recommended 
as well as extract of thymus. I have had little experience 
with the former and none with the latter. Thyroid, in my 
hands, has given no indication of its usefulness. On the 
other hand, Henry Heiman, in a personal commiunication, 
recommends its use empirically in certain cases which can- 
not be classified. He administers it in the dose of fromi ^ 
to I grain three times a day. It is my belief that the physi- 
cian who leans upon any drug therapy in this condition, to 



184 INFANTILE ATROPHY. 

the exclusion of the application of his knowledge of dietetic 
detail and individualization, will have poor results. Tinc- 
ture of nux vomica in mj to ^ij doses t. i. d., a. c, may be 
useful to increase the appetite and the motor function of the 
gastrointestinal tract. Extract of pancreatin and taka- 
diastase, alone or in combination, and rubbed up' with 5 
grains of white sugar may assist in protein and fat diges- 
tion. Paraf Javal's solution of strontium bromid may re- 
lieve colic, vomiting, and flatulency. A peaceful night may 
be secured by a single or double dose of 

B Sodii bromidi gr. ij. 

Tr. opii camph., -n^^ij. 

Syr. simpL, 

Aquce menthas pip., or 

Aquae camph., or 

Aquae anisi aa q. s. ad f5j. 

A few drops of HCl dil. miij-v may assist in the diges- 
tion of curd and prevent fermentation. An initial dose of 
-castor oil and spiced syrup of rhubarb, equal parts, will 
cleanse the bowels, relieve fermentative diarrhea, and is 
often of service. Later it may be followed by small doses 
of aromatic cascara for its tonic effect. Constipation may 
further be relieved by suppositories, enemas of olive oil or 
glycerin-and-soap water, and by the use of liquid paraffin 
preparations as before stated. Likewise it may be repeated 
that codliver oil, by inunction, is a valuable agent. 






CHAPTER V. 
RICKETS. 

Synonyms. — Rachitis, English Disease. 

Definition. — Rickets is a general disease occurring as 
the result of a perverted metabolism, the exact nature of 
which is not at present entirely understood. It manifests 
itself clinically by changes in the osseous, muscular, nerv- 
ous, and digestive systems. 

PATHOLOGY. 

While rickets depends upon some form of toxemia or 
metabolic disturbance which involves primarily the nervous, 
digestive, muscular, and osseous systems, the lesions char- 
acteristic of the disease are found only in the bones. 
Whether these changes are inflammatory or not is still a 
matter for discussion. The most marked changes are in 
the long bones and occur in the bone-forming centers, i.e., 
in the cartilage between the shaft and the epiphysis, and in 
the bone-forming or inner layer of the periosteum, and in 
the inner layers of bone which lie next to the medullary 
canal. In all tliese situations except in the neighborhood of 
the medullary canal, in health there occurs proliferation of 
cells which are later replaced by bone. This is accomplished 
by the deposition of inorganic substances. In this way the 
long bones grow in length and in thickness. The medullary 
canal is v/idened by the absorption of the layers of bone 
found in this situation. 

In rickets there occurs increased activity in the prolif- 
eration of cells in the hyaline cartilage between the epiph- 

■(185) 



186 RICKETS. 

ysis and the shaft and in the inner layer of the periosteum. 
There also occurs absorption in the medullary region, but 
decidedly less rapidly than in health. In addition there is 
an intense increase in the vascularization of the parts and 
there is a dimiinution in the deposition of inorg-anic matter, 
i.e., the quantity of organic matter far exceeds the inorganic. 
Thus the process occurring in health is reversed. The 
medullary canal becomes filled with rapidly proliferating 
cells that resemble granulation tissue. It can be seen, there- 
fore, that as a result of this increase in cell proliferation and 
in the lack of inorganic matter the epiphyses will become 
enlarged and thickened. Also the surface of the long 
bones will become irregular and the bones will readily 
yield to the effects of muscular traction, gravity, and atmos- 
pheric pressure. These bones also' readily bend or, if frac- 
ture occurs,^ it will not be cotnplete, but will be of the 
''green stick" variety. 

The same process of cell proliferation andi of increased 
vascularization, together with a scarcity of mineral con- 
stituents, takes place in the centers of ossification of the 
flat bones. This is especially true of the cranial bones. 
This gives rise to the formation of areas of thickness, or 
bosses. In those areas where the formation of bosses is 
absent, absolute or relative thinning of the bone results in 
craniotabes. 

The rachitic processes may become arrested at any time 
and complete absorption with perfect restoration tO' the nor- 
mal will occur. In fact it may be impossible tO' recognize 
that the present adult was a rachitic infant. The deposition 
of inorganic substances may proceed tO' such a degree as to 
cause the bone to become unusually hard or ivorylike 
(ebonizatioo). 



ETIOLOGY. 187 

ETIOLOGY. 

This disease is confined almost exclusively to infants 
who are artificially fed. When it occurs in the breast-fed 
it does not appear until late in infancy. Its incidence in 
these babies is evident beyond the first year, i.e., in infants 
wlio ha^'e been kept upon the breast too long and who are 
therefore receiving- food deficient usually in the elements 
which are essential to a vigorous metabolism. Just what 
exists in breast milk that prevents, and what is absent or 
present in cows' milk which permits or causes the symp- 
toms of rickets to appear, has not been clearly defined. It 
may be that the frequent disturbances of digestion to which 
artificially reared babies are prone, give rise to the develop- 
ment of enteric fermentation and the subsequent formation 
of toxins which, circulating in the blood, exert their dele- 
terious effects upon metabolism and nutrition, preventing 
the normal development of nervous, muscular, and; osseous 
tissue. Certain it is that clinical experience emphasizes the 
frequent occurrence oif rickets in individuals who receive a 
deficiency of fat and protein either by accident or through 
intention, the latter necessitated by the fact that the digest- 
ive powers are deficient in their ability tO' take care of these 
substances. Thus, where mixtures low in fat or low in 
protein are fed over a long period of time, rickets is likely 
to develop. Therefore infants who are continuously fed 
upon condensed milk, which is notoriously deficient in these 
substances and in mineral constituents as well, containing 
at the same time an excessive amount of carbohydrate 
(sugar), are frequently victims of this disease. Without 
protein and fat, normal development of bone, muscle, and 
nervous tissues cannot occur. In rickets these are uni- 
formly affected and exhibit a physical weakness and irri- 



188 RICKETS. 

tability that cannot be readily accounted for in any other 
way. 

Fat and protein, deficiency may occur not only, as just 
stated, as the result of a food mixture weak in these sub- 
stances, but may supervene as well where the formula for 
some reason disagrees and at the same time contains not 
only a sufficiency of the food elemients, but an excess. In 
the first instance they may be deficient for the indizndual. 
The personal equation therefore or the individual's idio- 
syncrasy must be considered in coming toi a correct con- 
clusion. In the latter instance the deficiency depends upon 
some digestive disturbance due to the excess per se, or upon 
intolerance of some other element, notably carbohydrate. 
In either instance the resultant is malassimilation — ^an 
amount of fat or protein deficient for the individual's 
proper metabolism, being absorbed. 

A deficiency of lime salts in the diet could readily 
account for the state of hyperirritability of the nervous 
system in rickety infants whO' are so eminently liable to 
convulsion. Lime is a nerve sedative. The salts of sodium 
and potassium are responsible frequently for nervous ex- 
citability. Therefore any food lacking a sufficient amount 
of calcium may predispose to this disease. The deficiency 
of lime in the tissues, theoretically at least, may be produced 
as in the case of fat and protein, by its absence or deficiency 
in the food, or by the failnre of the organism to assimilate 
it sufficiently, or by its increased elimination from the body. 
The last depends upon the ease with which it could combine 
with the active agent, presuming this toi be an acid, respon- 
sible for the disease; or it may be due to the untoward 
influence of diseased or functionally perverted parathyroids 
upon the maintenance of a proper calcium balance. 



ETIOLOGY. 189 

The frequent association of rickets with tuberculosis or, 
rather, the coimnon occurrence of tubercular lesions in 
rachitic children, is an ordinary clinical experience that re- 
quires no special emphasis. However, the degree of inter- 
dependence of these two diseases is not clear except in so 
far as it is a matter of common knowledge that all infec- 
tions are not only more likely to occur in the rachitic, but 
that they are marked by greater severity. Consequently, 
under these circumstances, these diseases offer a graver 
prognosis. In a word, the resistance is lowered in rickets 
and it is readily understood that the vitality may speedily 
be vitiated by a deficiency, especially of protein and of fat 
as well. 

A factor of prime importance in its bearing upon the 
de^^elopment of rickets is provided by faulty hygiene. 
Overcrowding, improper clothing, deficient aeration and 
sunshine are peculiarly common to those in whom this dis- 
ease appears with the greatest frequency. It may be that 
the frequent association of rickets and of tuberculosis finds 
its origin in the single etiologic factor of faulty hygiene, 
and this symbiosis, as it were, may represent nothing more 
than a coincidence in that the same factor provides a com- 
fortable habitat for the exciting cause of each. 

Race has its influence too. The disease in America is 
met decidedly most often in the Negro and next in the 
Italian immigrant. The filth and poor rearing of the former, 
and both these factors together with the excessively starchy 
diet of the latter, evidently provide sufficient reasons for the 
development of this disease. From this, however, it cannot 
be concluded that the rich are immune to rickets, although 
its incidence is decidedly less where material assets are suffi- 
cient to provide for the ordinary and the extraordinary 
requirements of existence. 



190 RICKETS. 

Sex has no bearing on the frequency oi rickets and 
heredity is without influence. The occurrence of several 
subsequent cases of this disease in all or in a part of the 
children of one family can be explained by the continuous 
presence of the same predisposing and exciting factors. 

As toi age, it must be stated that we are dealing here with 
rickets as we commonly see it in practice, and not with 
those questionable types of the disease (achondroplasia, 
fetal rickets) which depend upon some obscure uterine 
influence. Nor do I intend to dwell upon the rickets of 
puberty, but to confine the description toi a consideration of 
the disease as it is met in infancy and in childhood. It is 
rare in very early infancy. It may appear at 3 months. 
It is more likely to occur after 6 months and to manifest 
itself more frankly after i year of age. It is important to 
remember that the initial symptoms of the disease, to which 
reference will again be made, frequently appear quite early. 
These symptoms are mild at first and are therefore fre- 
quently unrecognized. My purpose in emphasizing* this 
fact depends upon a desire to insist upon our ability to abort 
the further development of this disease. If the proper 
hygienic and dietetic measures are inaugurated as soon as 
the significance of these initial features are recognized and 
appreciated, this statement becomes a truism. If the infant 
escapes, it is rarely possible that the condition will begin in 
childhood, i.e., after 2 years. 

Among predisposing factors of important moment, in 
fact regarded by some authors as sufficiently influential to 
be included among the most important exciting causes, is a 
deficiency of sunshine, fresh air, and the presence of damp 
siirroundings, — in a word, as before stated, a vicious 
hygienic environment. While it is true that the whole 



SYMPTOMS. . 191 

economy is depressed and vitiated by such influences and 
therefore predisposed to any disease, infectious or other- 
wise, we cannot help but recoignize the presence of some 
other factor as the active agent. All children subjected to 
such nifluences do not develop rickets and many acquire the 
disease who are not so surrounded. While! the disease 
occurs with greater frequency among the poor, it is also 
found quite commonly among the rich, and in the former 
instance its more frequent incidence is perhaps relative. 
Rickets is undoubtedly a disease of metabolism and diet. 
All other etiologic infliiences are predisposing and not active. 

SYMPTOMS. 

The most apparent symptoms o^f a well-developed case 
of this affection are referred to the osseous system. If, how- 
ever, careful investigation be made, certain other features 
may be detected earl}^ and protective measures be instituted 
to prevent the further development of the disease. This 
statement needs qualification, as it is possible that the 
process may be spontaneously arrested at any time. It is 
not always safe therefore to conclude that the cessation of 
symptoms depends upon any therapeutic or dietetic meas- 
ures which have been instituted. Nevertheless it is a clinical 
fact readily demonstrable by extended experience that, if 
certain precautionary measures, which will be pointed out 
later, are thrown about individual cases of artificial feeding, 
rickets need not and does not develop. 

Among the earliest evidences of a rachitic tendency, 
headsweatvng occurs, with much frequency. It is not 
pathognomonic in itself, as it may occur in healthy babies, 
but when associated with other conditions is eminently 
suggestive. The sweating may be confined to the forehead 



192 RICKETS. 

oir it may involve the occipital portions as well. It com- 
monly occurs during- the act of nursing and especially dur- 
ing' sleep. It miay be so profuse as tO' cause a corona of 
dampness to surround the spot where the head comes 
in contact with the pillow. Seasonal influences have no 
bearing upon its presence. It is continued well into 
childhood and may, in conjunction with draughts and sud- 
den exposures, be responsible for some of the congestive and 
infectious accompaniments or sequences of the disease 
(colds, pneumonia, bronchitis, etc.). 

CraniotabeSj or the thinning of the skull in spots, ap^ 
pears in some instances as early as the third month and is 
said, in a so-called congenital form, toi even precede this 
age. Of this variety of rickets I have met but few instances. 
Craniotabes may affect the parietal and frontal bones, but 
more commonly involves the perpendicular portion of the 
occiput. This is often flattened by the pressure of the head 
upon the pillow, and over the flattened area the hair is 
commonly worn away. This flatness must be distinguished 
from family resemblances and, before it is said to.be due 
to rickets, the head of the mother and especially that of the 
father, should be visualized. This symptom appears early, 
but is continued throughout the attack. When associated 
with an increase in the parietal and frontal eminences, 
which occurs as the result of an actual deposition of bone, 
and which does, not appear, as a rule, until after 6 or 8 
months, the head assumes the characteristic square appear- 
ance which is distinctive of the disease (Fig. 32). The 
circumference of the skull is increased. 

In young infants it is well to remember, especially after 
severe labor or in instrumental cases, that the shape of the 
head may become irregular or flattened as the result of 



SYMPTOMS. 



193 



molding or of pressure of the forceps. This change in 
contour, also, may persist for some weeks or months. In 
fact in non-rachitic breast-fed babies of vigorous develop- 




Fig. 32. — Square outline of head in rickets. 



ment, I have noted it as late as 8 months, and I have an 
impression that it may be permanent without causing any 
harm to the brain. This should be borne in mind when 

13 



194 RICKETS. 

deciding individual instances as to their rachitic or non- 
rachitic origin, and a careful history of the character of the 
labor should therefore be elicited. 

During early infancy and also throughout the attack, 
digestive disturbances are common. In themselves they 
present nothing characteristic of the disease, and whether 
they appear as a part of rickets or as interloping symptoms, 
or as a consequence of it or even if they possess an etiologic 
influence, is not clear in the nosology of this affection. 
Certain it is, however, that rarely is there met a case of 
rickets in which, at some time during or throughout the 
milk-feeding period at least, that digestive orders of one 
type or another are absent. Constipation is the more com- 
mon type of trouble, or this may alternate with diarrhea, in 
which the stools present features of fermentation and non- 
digestion. Vomiting is rare. The stools are often fetid. 
If constipated, they may appear hard and nodular. As has 
been stated, it cannot be determined with positiveness that 
these digestive crises possess an etiologic influence. There 
is no doubt, however, that, at least in a measure, they are 
responsible for the evidences of toxemia which are comr 
mon to rickets and which show themselves, as will be de- 
tailed later, by nervous hyperirritability with a tendency 
toward convulsive seizures. 

The liver and spleen are quite commonly enlarged. 
More significance attaches to the latter than tO' the former. 
It is difficult tO' determine whether splenic enlargement is an 
essential feature of the disease. My impression is that it is 
not, but that it depends upon toxemia, probably of intes- 
tinal origin, or it may be secondary to a tuberculous process 
to which rachitic children are so frequently subject. Poly- 
glandular enlargement occurs, too, with considerable fre- 



/ 

SYMPTOMS. 195 

quency. The postcervical glands are palpable, as are the 
glands O'f the axillae and those in the region of the groin. 
Undoubtedly, in many instances, the enlargements are 
tubercular, but not infrequently they represent simply the 
evidences oif general toxemia. 

Dentition is delayed in those cases in which the rickets 
appears before the time usually recognized as the physio- 
logic period at which teething should be inaugurated (6 to 
8 mionths). If the disease appear after this time the two 
lower central incisors may already have erupted. This 
must not be taken as a sign that' rickets does not exist. 
This important diagnostic point receives emphasis from 
Zappert. The subsequent dentition is delayed. Dentition 
is often irregular and rickety children may — although care 
must be exercised in coming to this conclusion, which 
should be reached only after every other possible etiologic 
influence has been eliminated' — suffer from reflex disturb- 
ances directly due to teething, oii account of the hyper- 
excitability of the nervous system. The slight irritation 
may be sufficient to produce irritability, nervousness, 
changes in disposition, rises in temperature, slight conges- 
tions, as coughs, otitis, and conjunctivitis. I know this is 
a dangerous dictum tO' put into the hands of the general 
practitioner and am conscious that it has been combated by 
much eminent authority. I feel, however, convinced, from 
cases which I have carefully studied, that, at times at least, 
dentition] and rickets produce a combination of etiologic 
factors which may be responsible for the conditions noted. 
At least no other factor was demonstrable and recovery was 
hastened, if not produced, by gum lancing. 

Muscular zv^eakness, tO' which reference will again be 
made, manifests itself early. There is lacking a feeling of 



196 RICKETS. 

tone, and this is evidenced by the inabihty of the baby to 
support its head upon the shoulders and by the backward 
curvature (rachitic kyphosis) of the spine when the infant 
is held in the sitting posture (Fig. 33). Ordinarily an 
infant should be able to support its head by the end of the 
second or third month. While the absence of the power so 
to do is not pathognomionic of rickets, it occurring in other 
conditions (hydrocephalus and amaurotic family idiocy), 
its association with the other symptoms enumerated fo'rms 
a highly suggestive phenomenon. 

An ammoniacal urine is a common occurrence in arti- 
ficially reared infants. It results, in all probability, from 
the excessive feeding of fats and sugars whereby these sub- 
stances are but partly transformed by the digestive glands. 
This results in the formation and absorption of fatty and 
other acids which combine with the alkaline bases of the 
body, producing an alkaline reaction of the urine and an 
increase in the ammonium output. This condition is espe- 
cially common in infants who show the other symptoms of 
early rickets. This statement must not be taken as a con- 
tradiction of the theory which emphasizes the possible 
etiologic effect of the deficiency of fat. On the contrary it 
accentuates its possible truth, viz., an excessive amoiunt of 
fat may be fed to the infant and yet its economy may re- 
ceive a minimum amount on account of its perverted trans- 
formation in the gut. 

The following symptoms, therefore, characterize the 
symptom-complex of early rickets, and may be nominated 
the preinonitory features of the disease, — not that it has 
not been already inaugurated, but that the progress may, in 
a sense, be halted by proper management. They are : head- 
sweating, craniotahcs, digestiz'c disturbances, constipation, 



SYMPTOMS. 



197 




Fig. 33. — Rachitic kyphosis. 



198 



RICKETS. 



late dentition, nervous irritability, muscular weakness, and 
ammoniacal urine. Craniotabes alone is characteristic. 
The rest, individually, signify nothing-, but the entire en- 
semble constitutes an entity of convincing interest. 




Fig. 34. — Rickets. Bulging forehead, enlarged radii, pot belly, skinny- 
legs, weak muscles (notice child cannot stand), flat-foot. 



OSSEOUS CHANGES. 
Other changes in the skull besides craniotabes occur. 
Great interest attaches to the anterior fontanelle. In 
rachitic infants, up to a certain age, this progressively in- 



OSSEOUS CHANGES. 199 

creases in size with the growth of the head. Ordinarily it 
should be closed by the eighteenth month. Ossification in 
rachitic children is delayed beyond this period, sometimes 
extending well into the second year. While the membrane 
does not budge, the cranial pulsation may be distinctly felt. 
The sagittal and frontal sutures likewise remain open. The 
forehead at times bulges and the frontal eminences are 
promiinent (Fig. 34). The facial bones are also involved, 




Fi§"- 35- — Rachitic rosary. 

especially the superior maxilla. The palate consequently 
presents a highly arched appearance. 

Chest. — The clavicles frequently present abnormal cur- 
vatures. The sternum is not uncommonly depressed below 
the surface, causing the characteristic "chicken-breast" ap- 
pearance or it may be unduly prominent, when the child is 
said toi be "pigeon-breasted." The ribs show changes 
Vx'hich possess considerable diagnostic import. At the 
coistochondral junction enlargements appear which may not 
only be palpated, but which are distinctly visible. This is 
called "beading" or the "rachitic rosary" (Fig. 35). This 
is only produced by rickets. It must be borne in mind. 



200 RICKETS. 

however, that in emaciated infants the costochondral junc- 
tion is always visible, and care must be taken not tO' regard 
this as rachitic unless there occurs distinct enlargement. 
The rosary may be present as early as the third or fourth 
month. 

The whole chest, as a rule, is flattened and narrow, 
especially in the upper poirtion. The lower portion flares 
outwardly and may appear actually everted. This causes 
the formation of a depression running outward and down- 
ward and involving usually the ninth, tenth, and eleventh 
ribs. It constitutes what is known as Harrison's groove. 
The amount of breathing space is limited on account of the 
flattening of the chest. This causes an improper develop- 
ment of the lungs and may constitute a potent factor in 
the occurrence of those pulmonary infections to which 
rachitic children are usually subject. Irregular malfoirma- 
tion of the chest may appear. One side may be prominent, 
the other flat, and serious depressions may be present. 

The spine presents abnormal curvatures. Rachitic 
kyphosis has already been mentioned. Scohosis is common 
and results directly from muscular traction upon the softened 
bones (Fig. 36). These curves may become accentuated 
after the child begins tO' walk. The rachitic curve, of 
whatever nature, is graded and can usually be made to 
disappear unless too far advanced, by causing the child to 
lie upon its stomach or tO' bend far forward. The curve 
involves many vertebrae. These characteristics distinguish 
the rachitic kyphosis from that produced by tuberculosis of 
the spine, in which the backward curvature is angular, not 
gradual, involving but two vertebrae as a rule and is fixed 
(Fig. 37), i.e., cannot be made to disappear by causing the 
child to lie upon its stomach or to bend far forward. In 



PLATE XI 




Tubercular kyphosis. The curve involves two vertebrae. In rickets 
usually four or five are involved and the curve is gradual. 



OSSEOUS CHANGES. 



201 



doubtful instances, an X-ray study is often of great assist- 
ance in making- this important differentiation (Plate XI). 
The rachitic pekns is flat and the anteroposterior 




Fig. 36. — Rachitic scoliosis. 



diameter is considerably shortened. This: type of pelvis, 
together with spondylodisthesis, may, in later life, give rise 
to serious obstetric complications. The pelvis is often nar- 



202 RICKETS. 

rowed laterally and may be so obliquely, due to the develop- 
ment of deformity more on one side than upon another as 
the result of muscular traction and pressure after the weight 
of the body rests upon the undeveloped legs. 

The legs of the rachitic infant are not commonly curved, 
although they may be. The normal bowing of the legs 
of the newborn infant must not be confused with rickets. 
The legs are small and undeveloped. In an infant i8 
moinths or 2 years of age they usually have the development 
of an infant 6 to 8 months of age (Fig. 34). The legs are 
small, flabby and hypotonic, and the reason for the inability 
to walk is readily recognized. As a rule the defoirmiities- do 
not appear until the weight of the body is supported by the 
legs, being directly due to the combined effect of pressure 
and muscular traction upon the softened bones. Flat-foot 
also occurs (Fig. 34). The epiphyses, just above the ankles, 
are commionly enlarged, but not to the same extent as the 
epiphyses of the forearms. The femur is rarely involved 
alone, although I have witnessed an almost complete spiral 
twist involving one femur. Anterior bowing of this bone 
is common. 

The deformities of the lower extremities may be worse 
on one side than on the other and they may assume many 
forms. For simplicity, however, the classification of Comby 
is exceptionally original and instructive. He causes the 
following figures and letters to represent the more common 
deformities : ( ) , parenthesis or O legs represent bow-legs, 
or genu vamm (Fig. 38) ; capital X, knock-knee, or genu 
valgum; K, unilateral genu valgum; D, unilateral genu 
varum (Zappert). Anterior bowing of the tibia is a 
common deformity (Fig. 39). 

The upper extremities are also^ involved. The humerus 



OSSEOUS CHANGES. 



203 




Fig. 2>7' — Tubercular kyphosis, showing the sharpness of the 
spinal curvature. Compare with X-ra}^ (Plate XI) of similar case in 
another patient. 



204 



RICKETS. 



may present thickening's and curves, but the greatest inter- 
est attaches to the forearms, especially the radii. The 
forearm may be bowed. The radii commonly present an 
enlargement of the epiphyses just above the wrists (Fig. 




Fig. 38. — Pot belly and bow-legs. 

34). These enlargements may be slight or very prominent 
and are pathognomonic of the disease. Although it does 
not assume the same prominence as it does in scurvy, 
tenderness of the bones occurs and may cause the child to 
cry when handled. 



OSSEOUS CHANGES. 



205 



The bony changes are progressive, but may, as pre- 
viously stated, become arrested at any time. After recovery 
they may entirely disappear. On the contrary, they may per- 
sist into adult life and thus may be afforded an instance 




Fig. 39. — Rickets. Anterior bowing of tibia and pot belly. 

of the hereditary influence in those cases where these 
changes, especially of the head, are visible in one or other 
parent or in an older child. Hereditary influence is not, 
hoAvever, always easily traced, for the reason, as stated be- 
fore, that in a single family or in a single race or section 



206 RICKETS. 

of the country the same etiologic or environmental forces 
may be operative. The bones become unusually hard in 
instances wherein the deformities persist beyond the sixth 
year. It is noteworthy, however, that in races in which 
rickets is cornmon, especially in the colored race, in which 
nearly every diild at some period of its development ex- 
hibits some type of rachitic deformity, slight or severe, very 
little evidence of the early presence of the affection can be 
noted in the adult. Neither do negro women suffer from 
obstetric complications more frequently than do white 
females. 

Rachitis of adolescence is a form of the disease which 
has its incidence about the age of puberty. It is little 
understood. The s}'Tnptoms, affecting commonly the legs of 
growing boys, which may become bowed or knock-kneed, 
appear at the time of heightened physiologic activity when 
changes are noted in the voice, when growth appears tO' be 
stimulated, and when hair appears upon the face, under the 
axillae, and over the pubic region. Flat-foot may develop 
at this time. So-called ''growing pains" may be present, 
although care must be exercised, otherwise an insidious 
attack of rheumatism may be ignored and be only recog- 
nized when the distinctive heart-murmur occurs. I should 
say that growing pains are more commonly rheumatic than 
rachitic. 

MUSCULAR WEAKNESS. 

This is an early and valuable sign of the disease, and its 
etiologic influence upon the occurrence of the bony defor- 
mities has been noted. The inability to support the head, 
as before expressed, is directly due to this cause. A nor- 
mal infant should sit up unsupported at 6 months. It 



MUSCULAR WEAKNESS. 207 

should crawl at 9 months, and should be able to stand by 
holding to a chair or the sides of its crib by 12 months, and 
should be able to walk without assistance by 15 or 18 
months. These physiologic expressions of development are 
absent in rickets. Together with other phenomena these 
findings form valuable diagnostic data. Walking may be 
delayed until beyond the second and third years. The 
inability to properly use the legs has given rise to the term 
pseiido-rachitic palsy, which must be distinguished from 




Fig. 40. — Rickets. Pot belly and protruding umbilicus. 

paralysis the result oi lesions of the nen^^ous system, espe- 
cially poliomyelitis. This distinction is largely made by 
the presence of other rachitic features and normal knee- 
jerks. The small, underdeveloped, flabby, hypotonic limbs 
(Fig. 34) may readily suggest atrophy to the unwary, but 
the fact that the condition is always bilateral and syn> 
metrical is against poliomyelitis. It must, however, be 
remembered that rickety infants, as well as others, may 
suffer from this disease and that paraplegia may be, though 
rarely, the type of paralysis present. 

This muscular hypotonia involves the muscles of the 
abdominal wall and the involuntary musculature of the 
intestines as well, and is directly responsible for the promi- 



208 RICKETS. 

nent belly which is so characteristic of this disease (Figs. 
34, 38, 39, and 40). At least in part, it is responsible for 
the constipation as well. The latter in turn causes the for- 
mation o>f gases which assist in increasing the abdominal 
distention. This phenomenon (meteorism) I believe toi be 
an important factor in the grave prognosis afforded to cases 
of pneumonia occurring in children with rickets. 

DENTITION. 

The importance of the irregularities of dentition in the 
early diagnosis of rickets has been described. The second 
dentition likewise partakes in this irregularity. The first 
teeth may fall out as soon almost as they appear, leaving 
the infant toothless until the second dentition takes place. 
This seriously interferes with the proper development of 
the jaw, which, already narrowed by the arching of the hard 
palate, causes the second teeth to be crowded. This results 
in overlapping from which directly ensue erosions and 
caries, together with dwarfed and ridged teeth. This is not 
true in all cases, as it must be emphasized that the fine 
teeth of many of the African race appear tO' present a note- 
worthy contradiction to this statement. However, it may 
be a fact that the disease in different races may act differ- 
ently, for carious and eroded teeth appear commonly in 
rachitic white children. The teeth may be notched or saw- 
like. In the first instance they must be distinguished- from 
Hutchinson's teeth, which involve, as a rule, the two upper 
central incisors, and which, in my experience at least, are 
very rare. I have met this deformity but twoi or three times 
in the past 14 years, although I have seen many children 
suffering from all varieties of luetic disease. 



NERVOUS SYSTEM. 209 

NERVOUS SYSTEM. 

An unstable nervous system constitutes a part of the 
general makeup of rachitic infants and children. Just why 
this is so, is not clear. It may be, in the light of quite recent 
investigations, with reference to spasmophilia, that the cal- 
cium balance is disturbed as the result of perverted func- 
tion or disease of the parathyroid glands, or both. Whether 
rickets and spasinophilia have a unifomi basis is by no 
meians clear. Certain it is, however, that an increased 
excitability of nervous tissue is more commonly met in the 
artificially fed, and therefore in rachitic infants more than in 
others. The response tO' the galvanic current is more rapid 
and certain and requires distinctly less current (spasmo- 
philia) in rachitic children. Tetany, convulsions, laryngo- 
spasm (laryngismus stridulus), spasmus nutans, all repre- 
sent evidences o«f increased nervo'us excitability and seldom 
occur in non-rachitic subjects. Intestinal toxemia and con- 
stipatfon, themselves due to rickets, may be the basic 
etiologic influences for many of these symptoms, which 
disappear or are decidedly benefited by a proper apprecia- 
tion of the situation, careful intestinal cleansing and an in- 
telligent adjustment of the diet. 

Blood. — Aside from secondary anemia, a decrease in the 
hemoglobin, which does not appear in all cases, the blood of 
rickets presents nothing of interest which is characteristic. 

Urine. — No distinctive changes in the urine are noted. 
The significance of the ainmoniacal urine of early infancy 
has been elsewhere detailed (Chapter II, page 112, — Fat 
Intolerance) . 



14 



210 RICKETS. 

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 

This disease is distinguished from all others by the 
osseous changes. The early recognition of rickets, before 
these changes occur or just at their beginning, has been 
described. A history of artificial feeding in the vast major- 
ity of cases, headsweating, craniotabes, late closure of the 
anterior fontanelle, irregularities of dentition, muscular 
weakness, enlarged abdomen, late walking, constipation, 
rachitic rosary, epiphyseal enlargements, curvatures of the 
spine and of the long bones, constitute the features essen- 
tial for diagnosis. 

It seems very unlikely that one should err by confusing 
this disease with another, and yet, before the description of 
it by Sir Thomas Barlow, scurvy was at first regarded as 
acute rickets and frequently confounded with it. The 
individual characteristics of the two: diseases are so' palpably 
and visibly different that their recognition should be ac- 
complished without difficulty even when they appear, as 
they sometimes do, simultaneously in the same subject. The 
pain and tenderness experienced by infants with scurvy, 
when handled or moved, is never so severe in rickets as to 
cause the patient to lie immobile for hours in one position in 
bed. Bleeding from the mucous surfaces, spongy purple 
gums, subperiosteal hematoma, anemia and purpura 
(hemorrhagic tendency) belong to scurvy and do> not 
occur in rickets (Chapter VI, page 223). 

The craniotabes of rickets must be differentiated from a 
similar condition due to syphilis. Clinically this is made 
possible by a history of repeated miscarriages, by the pres- 
ence of copper-colored skin lesions, mucous patches, des- 
quamative lesions of the palms and soles, wasting, and by 



DIAGNOSIS AND DIFFERENTIAL 1)1 ACiXOSlS. 211 

the possible incidence of bone involvement or deep ulcera- 
tions. Serologically, the Wassermann reaction offers in- 
valuable confirmatory evidence. The same clinical data are 
of assistance in differentiating' the eroded second teeth of 
rickets from those o-f syphilis. The characteristics of 
Hutchinson's teeth have been described. It must be remem^ 
bered that the two diseases may appear, especially in 
negroes, in the same individual. 

From tuberculosis of the bones it is not always, so easy 
to distinguish this disease. A careful history is important. 
The presence of ulcerations, pulmonary lesions, and the 
positive results obtained from the von Pirquet and the 
Moro test may assist, in solving the problem. It may not, 
however, always be thus easily accomplished on account of 
the frequent association of these twO' diseases in the same 
individual. The digestive disturbances and constipation 
peculiar tO' rickety children may be associated with irregular 
rises in temperature and emaciation. This causes added 
confusion in eliminating obscure tuberculosis, and should 
always be borne in mind. From^ tuberculosis of the spine 
(Pott's disease) the distinction has already been made 
(Chapter V, page 200). 

The head of rickets must be differentiated from the 
enlargement due to hydrocephalus. In the latter the charac- 
teristic squareness is lacking in the outline of the head. 
The sides are flanged outward and upward from a com- 
paratively small and pointed forehead, causing the for- 
mation O'f a vast expanse of vault consisting of thinned-out 
bone. The anterior fontanelle is not only opened but 
bulges, and the sutures are patent, while the marked dis- 
proportion between the size of the head and that of the face, 
which is small, is evident at a glance. The superficial veins 



212 



RICKETS. 



about the lateral aspects 




Fig. 41. — Double congenital 
dislocation of hip, to be dis- 
tinguished from rachitic lordo- 
sis or anterior curvature of the 
spine. 



of the forehead (temples) are 
very prominent. 

The points of difference 
between poliomyelitis and the 
pseudo-palsies of rickets have 
been detailed (Chapter V, p. 
207). Amaurotic idiocy is 
also characterized by muscular 
weakness. This disease is al- 
most exclusively confined to 
Russian Jews. It may present 
a history of heredity. Eye 
symptoms develop. The char- 
acteristic cherry-red spot (Hey 
Tyne) is seen by the ophthal- 
moscope upon the macula 
lutea. Blindness and convul- 
sions supervene, and death is 
the inevitable and humane re- 
sult. 

Cases in which intense an- 
terior curvature of the lower 
spine (lordosis) causes the hips 
to become prominent and mis- 
placed backward and upward, 
and especially when associated 
with symmetrical bowing of 
both femurs, and in which the 
lower portions of the body ap- 
pear shortened and likewise 
where the gait is somewhat 
waddling, often give the im- 



PROGNOSIS. 213 

pressioii of double congenital dislocation of the hips (Fig. 
41). A careful examination will reveal that motion is not 
limited in any direction, and that the heads of the bones are 
properly placed. iVn X-ray examiination affo.rds absolute 

data. 

COMPLICATIONS. 

Digestive disturbances havei been mentioned. The 
liability to convulsions and to other spasmodic diseases, 
laryngospasm, tetany, carpopedal spasm, spasmus nutans, 
nystagmus, infantile convulsions, has been discussed as well 
as the predisposition to tuberculosis and the association of 
scurvy with this disease in the same individual. The diffi- 
culties attending the eruption of the milk teeth in rachitic 
subjects need no further emphasis. Infants and children 
with rickets suffer from exudative phenomena — eczemas, 
intertrigOi — and are particularly prone to bronchitis, which 
has a tendency to become chronic and extensive, and 
to broncho'- and lobar pneumonia. The severity of all 
infections is intensified when occurring ini these patients, 
and the proignosis is always adversely influenced. Bony de- 
formity, especially that involving the pelvis, may be per- 
manent and seriously affect maternal and infantile mor- 
bidity and mortality on account of the subsequent dystocia. 

PROGNOSIS. 

Complete recovery from rickets is possible and common. 
The liability of the disease to be spontaneously arrested is 
frequently emphasized, especially when the infant reaches 
that period where it receives food other than cows' milk 
alone. The disease itself is rarely fatal, its lethal influence 
beiing exerted upon those conditions dangerous in them- 
selves and already mentioned as occurring as complications. 



214 RICKETS. 

TREATMENT. 

Prophylaxis. — This is best afforded by breast feeding. 
Either the milk of the mother or that of a wet-nurse, if 
feasible, should be supplied. Breast feeding, however, 
should not be continued beyond the first year. In fact if 
the infant has cut several teeth and the season of the year is 
not warm,, recourse may be had to solid or semisolid food 
at 9 or lo months, and in some instances earlier. I believe 
it to be advisable tO' offer such foods as well-cooked cereals, 
especially oatmeal, rice, barley, meat-juice, fruit-juices, 
eggs, and broth made from, vegetables (Chapter III, page 
146) at this period of the breast feeding. These substances 
should be given in small amounts and should be simply, but 
well, cooked, and exhibited mashed. The broth made from 
vegetables, slightly salted, may be given ad libitum as a 
drink instead of water. It supplies mineral substances, is 
antacid and laxative. 

The greatest difficulty arises in preventing the occur- 
rence of rachitic symptoms in infants who' are artificially 
fed. Much may however be accomplished if the case be 
watched and if simple though effective measures be conscien- 
tiously pursued. Infants require fat and they also require 
protein in sufficient amount, if rickets is to^ be forestalled, 
and yet both these substances may be productive of serious 
digestive disturbance. This view, with reference toi the in- 
digestibility oi protein, does not receive support from the 
present-day teaching of the German school of pediatrists 
represented by Finkelstein and his confreres. Reference 
has already been made tO' this (Chapter II, page 104) . Many 
American pediatrists have been profoundly influenced by 
the German, idea. I wish toi repeat that my own view, 
based upon considerable clinical experience, does not per- 



TREATMENT. 215 

mit me to subscribe to the dictum that cow-protein (un- 
changed mechanically or chemically) may be administered 
in incalculable quantities without harm. I beheve there- 
fore, and have been able to proive, at least to my own satis- 
faction, that it is important tO' commence artificial nourish- 
ment with small amounts of protein. This cannot how- 
ever be continued too long*, else rickets will occur. The 
amount must be slowly but persistently increased, and as 
soon as the signs of protein intolerance manifest them- 
selves measures must be taken, if not tO' reduce the amount 
(and this I do not advise at once), to modify it either 
mechanically or chemically. The methods for doing this 
have been discussed under the dietetic treatment of protein 
intolerance and under Marasmus (Chapters II and IV, 
pages 1 06 and 172). 

The same ideas apply to fat. Fat is necessary and must 
be fed in sufficient amounts, and as soon as the evidences of 
intolerance appear, it toO' miust be modified chemically 
(Chapters II and IV, pages no and 179). It may not be 
amiss to repeat, for the sake of emphasis, that cow-fat 
differs from the fat of human milk, and therefore 4 per 
cent, should never be exceeded, and that, as a matter of 
routine policy, it is safer to feed less than this amount. 
Where cow-fat cannot be tolerated at all, small doses of 
olive oil may be given on an empty stomach without gastric 
disturbance and with considerable benefit in ma,ny cases. 
The same is true, though to a less degree, of codliver oil, 
which may be advantageously employed as well, by inunc- 
tion. 

While sugar is necessary tO' produce heat and to con- 
serve protein, and while* it is, in my experience, usually 
well tolerated, care should be exercised not to feed it in 



216 RICKETS. 

excessive amoimts tO' the ne:glect of protein and fat. It 
makes fat babies, but weak and rickety ones. This is the 
reason why condensed milk continuously used as a routine 
food must be condemned. It is satisfactorry as a go-between, 
as a substitute for a brief period, but not longer without 
additional aliment. From 6 to 7 per cent, of sugar should 
ncA^er be exceeded. My routine preference is cane-sugar, 
for reasons already stated. 

Inasmuch as they contain mineral substances and pro- 
tein as well as starch, which, like sugar, conseiwes protein, 
I believe that cereal-waters for general use serve better as 
milk diluents than plain water. This preference refers 
especially to oatmeal and barley-water. 

All infants artificially fed should receive meat-juice 
early, and fruit- juices as well, on account of their mineral 
content and also because they are antacid, stimulating to 
the alimentary mucosa, and because they are quickly 
digested and absorbed. For this purpose beef -blood ex- 
pressed from fresh meat is administered in quantities of 
from J^ to 2 drams three times a day, exactly one-half 
hour before feeding, and the vegetable broth abovei re- 
ferred to should be given freely (Chapters III and IV, 
pages 144 and 176). 

Lime-water is of questionable service. It probably 
renders no assistance in the conservation of lime-salts in 
the economy. It may disturb digestion or produce consti- 
pation. In some instances, however, where these effects 
are not noted, it may be added in the amounts of from 5 to 
10 per cent, of the formula as part of the diluent. It is my 
belief that pasteurization or sterilization of milk (the latter 
should not be administered too long on account of the pos- 
sibility of scurvy) is not productive of rickets. However, 



TREATMENT. 217 

unheated, strictly fresh, certified milk is preferable, if 
obtainable. 

By the time an infant reaches 9 months or a year, it 
should receive undiluted cows' milk. The same additions 
to the diet, as mentioned above under Breast Feeding, 
should be given to babies who are being artificially reared, 
as soon as they erupt several teeth. 

Sunshine, fresh air, proper breathing space, good sleep- 
ing quarters, and warm clothing are essentials in the pre- 
vention of rickets. They are, unfortunately, not always 
obtainable by those who' need them most. Infants, espe- 
cially feeding cases, should not be kept in hospitals for any 
great length of time. They do badly as a rule, and fre- 
quently develop malnutrition and rickets. 

To summarize, it may be stated that the prophylaxis 
against rickets consists in breast milk, properly adapted 
cozies' milk containing a suMciency of fat and protein in 
digestible form, a proper amount of sugar, cereal-waters, 
meat- juices, fruit- juices, vegetable broths, the early use of 
solid and semisolid food, and a zvholesome environment 
zvhich secures to the infant the common-sense requirements 
of a normal existence. 

Dietetic Management Beyond the First Year. — Besides 
good milk, the main reliance should be placed upon a vege- 
table diet rich in salts, iron, and lime. Spinach is an 
unusually serviceable substance. The method of its prep- 
aration is discussed under Chapter III, page 147. Mashed 
skinned peas, mashed skinned lima beans, tender string 
beans, carrots, stCAved celery, stewed or raw onions, mashed 
baked potatoes, are also valuable. Eggs, soft-boiled or 
poached, form, a splendid addition on account of their high 
fat and protein content, and also because they contain 



218 RICKETS. 

phosphorus. Broths and soup and broiled scraped beef 
should be added as speedily as poissible. All foods should 
be simply, but well, prepared, and fed in amounts that will 
not overburden the digestion. Should trouble arise, no 
hesitancy should prevent a speedy recourse to^ the artificial 
digestants, pancreatin, taka^diastase, and pepsin. 

Medicinal Treatment. — There is no doubt that phos- 
phorus administered in suitable form exerts a valuable cura- 
tive influence, not only upon the pathologic processes which 
involve the boine, but upon the irritated nervous system, as 
well. It appears, from recent experiments, to increase 
calcium retention. It may be given alone or in combination 
with olive oil or, preferably, codliver oil. My experience 
verifies the statement of Holt, that a vegetable fat such as 
olive oil is often better borne than an animal fat. Espe- 
cially is this true if the olive oil be mixed with a small 
amount of grape- juice. Coidliver! oil itself is a valuable 
agent on account of its alterative qualities, the result of the 
iron which it contains, and because of its direct food value. 
It supplies fat in a suitable form without, as a rule, pro'- 
ducing gastric disturbance. As previously stated, it may be 
employed by inunction. A combination of phosphorus and 
codliver oil is represented by the classical prescription of 
Kassowitz : — 

I^ Phosphorus i part. 

Codliver oil looo parts. 

Sig. : f5j t. i. d. one-half hour after food. 

Jacobi years ago recommended phosphorus as a valuable 
therapeutic agent in the treatment of rickets. The usual 
dose for an infant under i year is ^/goo grain three times 
a day. 



TREATMENT. 219 

The preparations of calcium — calcium lactate gr. iij to 
gr. X, t. i. d., or the syrup of lactated calcium, f3j, t. i. d., or 
calcium in combination with phosphorus, as found in the 
syrup of hypophosphites compound of the U. S. P. — are 
of service too. Their direct effect in staying the rachitic 
processes has not been fully demonstrated, but they un- 
questionably, especially in the light of modern investiga- 
tion, exert a soothing influence upon nervous tissue and 
tend to prevent the occurrence of periodic or permanent 
nervous phenomena. 

When nervou's excitability does not appear as a promi- 
nent feature and where muscle weakness is unusually promi- 
nent, I have come to regard strychnine in the fonn of the 
sulphate gr. ^/2oo to gr. Vioo t. i. d. as a beneficent tonic 
when continued over a considerable period of time. Such 
alteratives and tonics as the syrup of the iodid of iron 
^v-x t. i. d. and the syrup of hydriodic acid ttix-xv, alone 
or together, or both combined with the simple or the com- 
pound syrup of hypopho'sphites, find a valuable field of 
sennce in the presence of anemia, chronic bronchitis, or 
glandular enlargements. These agents may be constipating 
or may interfere with digestion. For this reason care must 
be exercised in their administration. The combination of a 
simple tonic laxative, as the aromatic fluidextract of cascara 
sagrada, may render valuable assistance. 

My assistants in my clinic at the Mt. Sinai Hospital 
in Philadelphia (Drs. J. L. Werner and I. Rubin) have 
under similar conditions obtained excellent results by ad- 
ministering the following by hypodermic injection three 
times a week, especially where the anemia is associated with 
much splenic enlargement: — 



220 RICKETS. 

I^ Ferri citratis viridis gi". %o 



Sodii cacodylatis gr. 



Sodii glycerophosphat gr. i^ 

Aquae destill. (sterile) Vfixx 

M. et ft. ampulla no. j. 

Digestive disturbances are met as they arise, on gen- 
eral lines. An occasional intestinal cleansing with castor 
oil is serviceable. For the persistent constipation small 
doses of gray pov^der gr. J^ t. i. d. or oil enemas three 
times a week, abdominal massage or Philip's milk of mag- 
nesia TTlx-xl to every or tO' every other bottle, according to 
effect, or some palatable preparation of cascara ^x-xxx once 
or thrice a day are serviceable. Of late I have been im- 
pressed with the value oi some of the newer preparations 
of liquid paraffin (Chapter VIII). 

Non-medicinal Treatment.- Frequent cleansing of the 
skin surface is useful, especially when followed by thorough 
rubbing. It not only improves the circulation of the skin, 
but causes deeper and fuller respirations, and therefore 
assists in maintaining the symmetry of the chest. 

The first teeth of the rickety child should receive dental 
care. All cavities should be filled with cheap material and 
all hopelessly decayed teeth should be extracted. The 
mouth should be kept in as aseptic condition as possible. In 
this way alone may obscure toxemias, digestive derange- 
ments, and skin rashes be avoided. This applies to' other 
diseases as well as to rickets. 

Much may be done by way of prophylaxis to prevent 
the occurrence of severe deformities by making an early 
diagnosis of the disease. Rickety children should not 
be made to stand before they are able or before they do so 
voluntarily. After they do commence, tO' stand the in- 
dividual should be studied, and if his legs appear unusually 



TREATMENT. 221 

small and weak, he should not he encouraged to bear his 
weight upon them. Braces should not be applied until the 
child walks, but should then be provided early and be worn 
continually, either to prevent the occurrence of deformity or 
to secure its early correction. A discussion of the types of 
braces or of the various orthopedic maneuvers employed for 
the correction oi the osseous deformities, temporary or per- 
manent, are beyond the scope of this volume and cannot be 
treated in detail. 



CHAPTER VL 

SCURVY. 

Definition. — Scurvy is a disease of metabolism depend- 
ing upon an as yet unknoAvn etio-logic factor. It is con- 
sistently associated with artificial feeding. The diet is 
commonly lacking in raw animal and vegetable products. 
It is characterized by a premonitory period of peevishness 
and irritability, which is later followed by hyperesthesia and 
actual pain and tenderness in the bone. Hematuria and 
subperiosteal, gingival, and visceral hemorrhages complete 
the clinical picture. 

ETIOLOGY. 

The actual determining cause is unknown. The disease 
is probably non-infectious, although the subnutritional state 
predisposes to secondary infection. Metabolic disarrange- 
ment is probably responsible for the presence in the blood 
of some as yet undetermined chemical compound or com- 
pounds from the effects of which the symptoms arise. The 
disease occurs with the greatest rarity, if at all, in the 
breast-fed and only in those cases in which maternal nursing 
has been continued over too long a time (15 or 16 months). 

Children fed for a long period upon the patented foods, 
which are made with or without milk, appear to suffer most. 
Plain boiled milk, contrary to the usual teaching, does not, 
if the boiling be but momentary, appear often toi produce 
scurvy — at least, in my experience. Prolonged boiling, on 
the other hand, with the addition of a patent food, deter- 
mines most cases. It is uncommon under 3 months. Most 
cases appear after 6 months. It is rare after 18 months. 
(222) 



CLINICAL HISTORY AND SYMPTOMATOLOGY. 223 

PATHOLOGY. 

The characteristic lesion of the disease is distinguished 
by hemorrhage under the periosteum of the long bones and 
by hemorrhagic infiltration of the internal organs. These 
extravasations of blood are large or small, and may be 
niicroscopic. Bone changes also occur, but are less marked 
than in rickets. Epiphyseal separations are common. The 
extravasated blood undergoes absorption and organization, 
leaving behind hard, thickened areas. 

CLINICAL HISTORY AND SYMPTOMATOLOGY. 

The infant has never received breast milk or, if it has, 
it has been, as a rule, discontinued early and usually for an 
insufficient reason. On the other hand, a history of pro- 
longed exclusive breast feeding may be, in very rare in- 
stances, obtained. Personally I have never met a case. It 
has been placed upon an indifferently modified cows' milk, 
alone or in combination with a patent food. Frequently, a 
histoiry consisting? of the exclusive feeding of condensed 
milk is given. In most instances the food has been sub- 
jected to prolonged boiling, althO'Ugh this is not constant. 
The infant has never received, or at least has received very 
irregularly, animal or vegetable juices. The baby may or 
may not have been placed upon the artificial food on ac- 
count oi a digestive upset while on the breast (very com- 
mon reason), or there may be a digestive upset after being 
placed upon the modified milk. For this reason one patented 
food after another has been tried. The distinguishing 
point to remember is that the food lacked freshness, or per- 
haps, what is a somewhat poor but more expressive state- 
ment, it lacked the vital principle of rauntess. 



224 SCURVY. 

The sweet-dispositioned baby which has been growing 
fat, now becomes irritable and peevish. It cries and 
whimpers when it is approached, and especially when picked 
up or while being bathed. If it has zmlked, it now refuses 
to do SO', or it will not stand, crying when placed upon its 
feet. This occurring in a previously healthy infant of 1 1 o^r 
more months of age is so characteristic of this disease that 
it assumes almost pathognomonic importance. A pallor of 
the skin is noted and the child is content to lie in its crib 
undisturbed for days at a time. This is a very characteris- 
tic and early feature. The bowels may be normal, or there 
msLy* appear evidences of indigestion and the movements 
may contain visible or occult blood. Helena is rare. 
Hematuria occurs and may be the only symptom,. The 
amount of blood varies as the intensity of the disease. It 
may only be detected by the microscope. Albumiin and 
casts are usually present with the blood, but they are not an 
essential part of the disease and may represent a true com- 
plicating nephritis. Pus, from an associated pyelitis or 
cystitis, has also been found in the urine. 

A characteristic symptomi of the disease is subperiosteal 
hemorrhage. It may be the first intimation of the real 
nature of the child's indisposition. The previous ill-health 
described has been present, but an incoirrect interpretation 
has been placed upon it, the most likely diagnosis tO' have 
been made being rheumatism. In the history it is so com- 
monly stated by the mother that her infant has been treated 
for rheumiatism that suspicion of scurvy should be aroused 
by this fact alone. The hemoirrhages occur usually under the 
periosteum of th© long bones, most often the femur and 
tibia — the lower extremities being affected with greater 
frequency than the upper. The subperiosteal extravasations 



PLATE XTI 




The appearance of the gums in a case of infantile scurvy. 
Note swollen condition and purplish discoloration, especially 
around the bases of the erupted teeth. This condition is 
pathognomonic of the disease. 



1 



CLIxNICAL HISTORY AND SYMPTOMATOLOGY. 225 

of blood cause swellings, which appear with more or less 
suddenness. The swelling is large or small, as die case may 
be; is more or less pyramidal in shape, occupying usually 
the lower third of the bone near the joint, but not involving 
it; is of a doughy feel, and may give the sensation of fluid 
under tension, distinct fluctuation being rarely experienced 
(Fig. 42). Fig. 43 represents the same case cured, but still 
showing evidences of rickets. The superficial veins over the 
swelling may be prominent and the extremity below is often 
edematous. The edema may, however, be present in both 
feet, being independent of the pressure exerted by the ex- 
travasated blood. 

These hemorrhages may occur in any part of the body, 
either into^ the viscera, the walls of the intestine, the menin- 
ges, or into the cavity of the orbit. The last causes sud- 
den and, for a time, unexplainable unilateral, rarely bi- 
lateral, exophthalmos. The blood may find its way into the 
eyelids or conjunctiva, giving the appearance of the so- 
called black eye which is erroneously thought to be due to 
trauma. The extravasated blood causes pain by pressure. 
As a result the infant lies in a more or less characteristic 
attitude. The thighs are usually abducted and rotated out- 
ward. Epiphyseal separation may occur as a result of the 
large extravasations of blood. This condition may be 
erroneously diagnosed epiphysitis, the underlying scurvy 
being entirely ignored. In fact all real instances of appar- 
ently primary or spontaneous epiphysitis should be regarded 
as scorbutic until it is conclusively proven that they are not. 
Aside from the hemorrhagic symptoms which are, in them- 
selves, convincing, the X-ray provides a very easy and 
valuable means of distinguishing an epiphyseal separation 
due to hemorrhage, from an acute epiphysitis. Likewise in 

15 



226 SCURVY. 

the latter the differential leucocyte count would indicate an 
increase in the polymorphonuclear cells. 

The mouth appearance is characteristic. The gums, 
especially, if the teeth are not present, may appear normal. 
On the other hand, they may be spongy and red, bleeding 
with great ease. Most distinctive is the picture if the teeth 
have been erupted. Around the base of each tooth, or per- 
haps covering the whole cusp, except the cutting edge, the 
gums are purplish, red, and swollen (Plate XII). The 
rest of the gum may appear normal or, as the result of 
secondary infection, gingival ulceration has been noted. 
Extravasated blood into the mucous membrane of the hard 
palate may appear as a more or less circimiscribed, bluish 
swelling. 

HemoTrhages into the viscera, as the liver or spleen, or 
into the walls of the intestines (Still) occur, but are very 
difficult to recognize when present alone. The hlood shows 
nothing typical other than the evidences of symptomatic 
anemia, slow clotting, and; leucocytosis as the result of the 
hemorrhages. The hemoglobin averages about 45 per 
cent., but may go lower, and the red cells number about 
2,500,000 or less. Care should he taken not to regard the 
presence of leucocytosis as an evidence of inflammatory 
disease, else the diagnosis may he clouded. In this connec- 
tion the diiferential count zmll reveal the absence of an in- 
crease in the polymorphonuclear cells when the leucocytic 
excess is not dependent upon a pdmary or secondary infec- 
tious process. Purpuric eruptions occur, but are neither 
constant nor as common as usually supposed. The single 
lesions may present the appearance of a traumatic ecchy- 
mosis, and in fact may be directly dependent upon slight 
trauma inflicted simply by handling the child. The de- 



CLINICAL HISTORY AXD SVMFTOMATOLOGV 



227 



pendent portions of the body are more commonly involved. 
Epistaxis, while rare, has been noted. The temperature of 
scurvy cases, while oiten normal, is just as frequently 
elevated to ioi° F. or to2° F. The fever is most likely 




Fig. 42. — Scurvy. Subperiosteal hematoma of right thigh, 
edema of legs and left thigh. 



dependent upon the absorption of aseptic blood-clot and 
fibrin. Hyperpyrexia is rare and is usually dependent upon 
secondary infection of the blood-clot, or is due tO' pyelitis 
or cystitis. 



228 SCURVY. 

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 

The case represented by Fig. 42 was submitted toi the 
staff connected with a large children's clinic, for an opinion. 
Each physician was permitted tO' separately elicit the his- 
tory and to examine the patient. The following diagnoses 
were received : sarcoma, rheumatism] osteomyelitis, perios- 
titis, tuberculosis, rickets, and ummited fracture. Sarcoma 
may be eliminated by the previous history, the compara- 
tively sudden appearance of the tumor, the condition of 
the gums, other evidences of hemorrhagic extravasation, 
and the rapid recovery upon the institution of proper 
dietetic management. Rheumatism is distinguished by 
polyarticular involvement, acid sweats, characteristic tem- 
perature, and its comparative rarity during infancy. The 
joints in scurvy are rarely involved. This is the most com- 
mon mistake in reference to the diagnosis of scurvy. It is 
so common that it is of sufficient importance to repeat that 
the very fact oi making a diagnosis of rheumatism in an 
infant is in itself sufficient evidence tO' arouse suspicion of 
the presence of scurvy. Osteomyelitis and periostitis may 
cause some confusion. They more commionly attack the 
tibia. There may be a history of trauma. There is an 
absence of hemorrhages. The temperature is decidedly 
septic and the skin over the bone is reddened and inflamed. 
Leucocytosis is usually over 20,000 and is distinguished 
by an increase in the polymorphonuclear cells. Tuberculosis 
may be excluded by the history, the longer duration of the 
case, the. presence of tuberculosis elsewhere in the body, the 
absence of hemorrhages, and a positive Moro^ or von 
Pirquet reaction. Rickets may accompany scurvy as in the 
case here illustrated. Pure rickets, however, presents a 
different history and is unassociated with a hemorrhagic 



DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 229 

tendency. In rickets the bony enlarg-ements affect the 
epiphysis and are distinctly localized. The other lx)ne 
changes usually take the form oi curvatures and are brought 




Fig. 43. — Same child after recovery from scurvy. Note absence of 
swelling of extremities. Child still undernourished ; still shows some 
evidence of rickets (square head, beaded ribs, relaxed belly). Ex- 
pression, however, is natural. 

about by the action of gravity and muscular traction and 
atmospheric pressure. Uniimted fracture usually gives a 
history of trauma and, while some resemblance betAveen it 



230 SCURVY. 

and scurvy may exist, the mistake should not occur if the 
latter be borne in mind. The distinguishing; features of 
epiphysitis have been indicated, except that epiphysitis mo«t 
often involves the lower forearm. Of especial importance 
is the history of a perverted dietary and the early develop- 
ment of anemia, peevishness, crying when handled or 
bathed, and a very evident desire toi lie in bed undisturbed. 

PROGNOSIS AND COMPLICATIONS. 

When detected sufficiently early, before the infant's 
strength is exhausted, the outlook is good. Recovery is 
prompt and permanent. A marked change is noted usually 
in four or live days, although cases which are recognized 
late may extend over four or five weeks. If the case has 
progressed too far, death from asthenia occurs. Cerebral 
and visceral hemorrhages, secondary infection, epiphyseal 
separation, occur in neglected cases.- Those cases which 
present a delicate digestive apparatus or food idiosyncrasies 
OT are complicated by severe rickets, end slowly in recovery, 
or may terminate fatally. 

TREATMENT. 

This is purely dietetic. 

Prophylaxis.— Breast feeding up to 9 months or a year 
and not longer. If the child is artificially reared, prolonged 
boiling of the food is not permissible without the addition 
of other food. Fresh fruit-juices, — orange, plum, grape, — 
as well as fresh beef -juice, are to be fed regularly to the 
infant between milk feedings. Patented foods, especially 
those that require boiling, are to be eschewed as a permanent 
diet. 



I. 

TREATMENT. 231 

Treatment of Attack. — The best possible hygienic sur- 
roundings should be secured. In the beginning the infant 
should not be unduly disturbed by toO' frequent attempts 
to bathe it or to change its clothes. Scorbutic swellings, no 
matter hoAv muchi they may resemble inflammatory exu- 
dates, are under noi circumstances tO' be incised. Such a 
procedure may cause fatal hemorrhage or secondary infec- 
tion. Where it is impossible for the mother to suckle her 
babe, wet-nursing, if feasible, should be secured. In the 
absence of either of these sources of food, raw cows' milk 
adapted to the child's age and digestive capacity, is the 
remedy that will bring about a cure. Fruit-juices — prefer- 
ably orange-juice from 2 to 3 ounces a day — must be ad- 
ministered, but not just before or after a milk feeding. If 
necessary it may be sweetened, or if not available the juice 
of apples, plums, or grapes may be substituted, although 
orange-juice is preferable. From one-half to one whole, 
miealy, haked or boiled potato, given plain or creamed with 
milk, possesses an excellent antiscorbutic effect. Fresh 
beef -juice (not beef -tea or beef-extracts), fluidounce ^ to 
fluidoiince i, a day, must also be given. Gelatin may also be 
of some assistance. 

There is no special medicinal treatment, except the use 
of tonics to combat the anemia. The hypodermic adminis- 
tration of the citrate of iron alone, or with sodium cacody- 
late, admirably fulfills this indication. 



CHAPTER VII. 

VOMITING. 

This condition is not a distinct disease entity. On the 
contrary, my main purpose* shall be to emphasize its impor- 
tance as a symptom. Regarded as such, it becomes neces- 
sary to study in detail the etiologic factors concerned, so 
that an intelligent therapy may be arranged. It follows 
therefore, too, that each case must be individually consid- 
ered. The causes of vomiting differ somewhat in infancy, 
i.e. J under 2 years, from those occurring in early childhood 
(after 2 years) ; hence a more or less elastic subdivision 
may be formed as follows: No. i, Vomiting of Infancy; 
No. 2, Vomiting of Early Childhood. 

VOMITING OF INFANCY. 

In the early days of life, up to the age of 6 months 
the stomach is almost entirely covered by the large left lobe 
of the liver. When the stomach is filled the liver, there- 
fore, interferes with the rapid emptying of the gastric con- 
tents through the pylorus and, by pressure, causes the 
stomach to assume a more vertical position than when 
empty. This, together with the undeveloped valve action 
of the cardiac end, permits and explains the early re- 
gurgitation of food at this time of life. This type of 
vomiting or, better called, regurgitation, occurring imnie- 
diately after feeding, may be regarded almost as physio- 
logic, or simply as the overflowing of an overfilled reser- 
voir. In some cases it does no harm. In others, should it 
become excessive, it decidedly interferes with the nutrition 
(232) 



VOMITING OF INFANCY. 233 

of the infant. It becomes less frequent after 6 months, as 
there is, after this period, a decided increase in the greater 
curvature and the cardia, together with the development of 
the valve-like action at the cardiac orifice. Nor does the 
liver cover the entire organ. 

The prevention and cure of this variety of vomiting can 
often be readily accomplished by the forming of regular 
habits which permit of a correct feeding inten^al, and of the 
administration of the proper amount of food at each feeding. 
The infant must not be picked up immediately after its 
meal, and it must be laid upon its right side so^ that the 
rapid emptying of the stomach may be favored. 

The pernicious habits of irregular feeding and of. over- 
feeding are responsible for the vast majority of cases of 
functional vomiting occurring under i year in both the 
breast- and in the bottle-fed. In making this statement my 
personal experience is not in accord with certain teachers 
who advocate the giving of as much food to an infant as it 
wants, and as often as it wants it. Physicians are led into 
this error by regarding crying as a sure sign of hunger. 
They forget that the baby may be thirsty ot otherwise un- 
comfortable. 

The giving of food, on account of its warmth or pleas- 
ant taste, may momentarily relieve colic or distract the 
baby's attention and thereby quiet it. The pain returns 
with increased vigor and is again assuaged in a similar 
manner. Simple regurgitation of food now becomes a con- 
dition of true vomiting, dependent upon fermentation and 
dilatation, if not upon actual gastritis. The best argument 
tliat an infant should not be permitted to nurse until it 
voluntarily stops, is furnished by anatomic and physiologic 
facts. The capacity of an infant's stomach at birth is, 



234 VOMITING. 

approximately, an ounce and, accoirding to the figures offered 
by Cotton, this develops as follows: — 

End of first month 2^ oz. 

End of second month 3^ oz. 

End of third month 4>^ oz. 

End of fourth month 5 oz. 

End of fifth month 5^ oz. 

End of twelfth month 8j^ oz. 

My own experience, based upon actual weighing experi- 
ments, with quite a large number of breast-fed babies, be- 
fore and immediately after feeding, as to the stomach's 
ability to hold the amounts at the various ages indicated, 
would place the figures even somewhat lower. However, 
taking these as a guide, one cannot help but see how 
ridiculously foolish: it is, not to' say dangerous, toi offer 
to an infant under i month of age, from 4 toi 5 ounces ot' 
food at a nursing, as I frequently see done by men of large 
patronage and experience. This practice is pernicious and, 
when it induces vomiting, the condition is most difficult to 
control, even after the quantity is reduced. The reasons 
for this have been mentioned, namely, dilatation and atony, 
if not true gastritis. A safe rule, perhaps, would be to 
regulate the quantity fed in such a manner that it repre- 
sents ift^ ounces the child's age in months up to about 6 
months. After this the rate of progression should he 
slower (Chapter II). 

What is true of the quantity fed as a cause for vomiting 
is likewise true of the interval of feeding. Noi new food 
must be put into the stomach until the organ has emptied 
itself, regained its tone, and rested. Feeding, too fre- 
quently is as pernicious as too much food at a feeding, and 
amounts to the same thing, and is productive of the same 
ill-effects. It retards gastric digestion, impedes gastric 



VOMITING OF INFANCY. 235 

motility, and hence produces fermentation, colic, vomiting, 
and other symptoms upon which depend, in turn, the early 
evidences of malnutrition and essential marasmus. It is a 
notorious fact, readily confirmed by anyone who' has had a 
large experience in the management of these wasted babies, 
that the vast majority of them present a history in which 
overfeeding or too frequent feeding, or both, are the de- 
termining etioilogic factors. While zvhat an infant receives 
as food is important, it is just as important hozu it gets it 
and when it gets it. The caprices of its appetite or the 
whims of its caretaker are poor judges of what is necessary 
to supply its nutritional demands. 

The prevention and cure of this type of vomiting is 
self-evident, viz., the proper regulation of the food as to 
the qiiantity and the interval of feeding. The first has 
already been discussed. As to the second, no fixed rule will 
apply to each infant. The individual must be studied to 
learn his peculiarities, but when once the interval has been 
determiined it must be adhered to strictly. 

If the infant is not tO' vomit after feeding, it is not to 
be picked up or shaken, but after its meal it must be per- 
mitted toi lie quietly undisturbed, preferably on its right 
side. The time spent at the breast should vary from ten to 
thirty minutes, dependent upon the age of the infant and 
the interval of feeding, but under no circumstances should 
the meal be interrupted to be resumed again later. These 
rules apply to the bottle-fed, as well as to the breast-fed 
baby. 

The causes of vomiting thus far detailed apply to both 
classes of infants. There are, however, certain conditions 
which, while applicable to all infants, apply with more 
emphasis to the breast- or to the bottle- fed, as the case 



236 VOMITING. 

might be. Thus we have the importance of the composi- 
tion of the food applying with greater force to the bottle 
baby, although its significance cannot be ignored entirely 
when dealing with breast-fed children. The ingredients of 
the food most commonly at fault are the fat and less often 
the sugar, and to those accustomed to dealings with these 
cases the clinical symptoms are significant and frequently 
permit of a correct interpretation (Chapters II and IV). 

The vomitus due to excessive fat is distinctly sour and 
acid, smelling like rancid butter. It contains lumps; of 
coagulated calcium casein, holding within their meshes the 
fermenting fat which is soluble in ether and reacts charac- 
teristically with osmic acid, and to Sudan III. These pieces 
of curd are large or small and have a yellowish appearance. 
The time of vomiting in this condition is important, occur- 
ring from one hour to one and a half hours after feeding, 
i.e., after fermentation has occurred. The vomiting due to 
excessive feeding or to tooi frequent feeding, on the other 
hand, occurs immediately after a meal, the vomited matter 
being- as a rule, in the beginning, tmchanged and frequently 
uncoagulated. With vomiting due to fat intolerance there 
are characteristic bowel symptoms as well which have been 
discussed in Chapters II and IV, pages iii and 179. 

The remedy, if in the breast-fed, is to attempt the re- 
duction of the fat percentage by modifying the mother's 
milk. This is, as a rule, more readily accomplished than to 
increase the percentage where the fat is tooi low. The free 
drinking of water by the mother, the partial or complete 
exclusion of milk, soup, malt liquors and meat from, the 
dietary, increase in exercise, and the occasional use of laxa- 
tives are measures well calculated to accomplish the result 
desired. In rare instances the infant's stomach should be 



VOMITING OF INFANCY. 237 

washed once or twice. This appHes with greater force to 
the bottle-fed. Each nursing should be preceded by an 
ounce or two orf some cereal-water, preferably made from 
barley or wheat. Occasionally these cases progress more 
rapidly if the meal is followed by a grain or two of extract 
of pancreatin, used simply as a temporary means until the 
fat reduction is accomplished. Where it is impossible to 
reduce the fat the breast milk may be withdrawn and 
diluted with a cereal-water and fed from a bottle, or the 
first milk may be expressed or pumped from the breast, and 
the infant allowed to/ suck ''middle" milk or "last" milk so 
called. Very rarely the breast milk may be withdrawn and 
pancreatized. Any of these maneuvers, alone or in combina- 
tion, will usually suffice to accomplish the desired result in 
breast-fed babies. 

In bottle babies, as a rule, the problem is simpler. Here, 
following the stomach washing, the infant is fed for twenty- 
four hours upon some cereal-water or weak tea slightly 
sweetened with sugar oir with saccharin (gr. j to' a quart). 
The physician may then, by increasing the dilution of whole 
milk, so adjust the fat content as tO' suit the infant's digestive 
capacity. This failing, resort may be had to pancreatiza- 
tion or tO' the temporary feeding of whey, which is weak in 
fat. In rare instances, where vomiting continues and the 
infant appears to be intolerant of all fat, we may employ, 
with success, modifications of skimmed milk, eiweissmilch, 
buttermilk, or condensed milk. 

Sugar is rarely a cause of vomiting, but may be. It 
practically never is in the breast-fed. When a source of 
trouble, it is not uncommonly associated with a waten^ 
diarrhea. The vomitus is watery, sour, and hot, and occurs 
late after feeding and may cause crying, as the regurgitated 



238 VOMITING. 

material may produce a burning pain in the esophagus. 
The remedies consist of an initial purge, rarely a stomach 
washing, less often a colonic flushing, and the reduction in 
the amount of sugar. Buttermilk and eiweissmilch, which 
are sugar-poor, may be of service. 

The protein rarely causes vomiting, unless given in ex- 
cessively large amounts, when the resulting curd acts as a 
foreign body and is expelled. Sodium, citrate added toi the 
foirmula in the strength of i to 2 grains for every ounce of 
milk and cream in the mixture has, in my experience, been 
of considerable aid in overcoming vomiting due toi tough 
curd foirmation in the stomach. 

As a cause for vomiting congenital pyloric obstruction 
is too rarely recoignized. I have elsewhere called attention 
to this fact, but wish here tOi offer what follows, as a safe 
guide, with the hope that others will adopt it as a, means 
for diagnosis and for saving the lives of many infants 
whose condition becomes hopeless before it is recognized, 
and whose deaths are largely ascribed to other causes, viz., 
that all cases of vomitings beginning at birth or shortly 
thereafter and continuing in spite of a reasonable amount of 
food manipulation, especially in breast-fed infants, or in 
artificially fed ones as well, are to be regarded as cases of 
pyloric obstruction, until it can be proved that they are not. 

In direct opposition to this fatal type of persistent vomit- 
ing should be mentioned a type of persistent vomiting or 
spitting up!, of an entirely benign nature. This occurs in 
either perfectly healthy breast or bottle babies who per- 
sistently and steadily comtinue to thrive and to gain in 
weight. An adequate explanation for its occurrence is 
difficult or almost impossible of determination, and no 
treatment seems to be of avail. Dietetic manipulations are 



VOMITING OF INFANCY. 23^ 

without effect and usually do harm by interfering with the 
infant's nutrition. The weight either remains stationary or a 
slight loss is recorded. It continues until it is spontaneously 
arrested as stated, and not infrequently occurs in perfectly 
healthy breast babies, where the breast milk, by repeated 
analysis, is found to be perfectly normal. While a cause 
for it undoubtedly exists, the most plausible explanation is 
a vicious habit, which, perhaps, has its origin in faulty 
hygiene. The condition may be cautiously diagnosed and a 
good prognosis given only when all other possible causes 
have been entirely excluded. 

A type of vomiting closely akin to this is that due 
directly to nervous irritability or nerve exhaustion or even, 
perhaps, to a nervous habit or tic affecting the gastric 
musculature. While the exact nature of the mechanism of 
the nervous invoilvement is not easy of detection, clinical 
experience and close observation will sooner or later unmask 
the true nature of the condition as to^ its nervous oirigin. 
These babies fuss while nursing the breast or sucking the 
bottle — oir if this does not occur, as soon as the feeding is 
finished, they begin to fret or to squirm and wriggle and 
distort their features) until vomiting occurs, either force- 
fully or not so. The vomiting may be preceded by chewing 
motions. The nutrition does not always suffer seriously 
unless the food is changed too often, especially as is com- 
monly the case if the food be weakened too much. The 
reason why they maintain a stationary weight or lose but 
slowly is because many of these babies will nurse well at 
night and retain their nourishment. This is an important 
point in making the diagnosis, but is often not elicited 
except by accident or only after careful inquiry. I have 
met many such cases after they have gone the rounds of 



240 VOMITING. 

many physicians and have run the gamut of an innumerable 
variety of milk formulas and patented foods. These infants 
resemble the adult neurasthenic whose distressing symp- 
toms are commonly relieved after sunset — a strong point 
always in the diagnosis of nerve exhaustion. Some o<f 
these babies will only nurse well and retain their nutriment 
if it is given to them during sleep, they positively refusing 
to take it while awake, immediately rejecting that which 
was forced upon them. 

The diagnosis of nervous vomiting must, especially in 
infants, be made with extreme caution and only after all 
other possible factors have been eliminated. In considering 
the treatment of these babies the most important thing to 
learn not to do is to change the food too often. Once the 
diagnosis is made, the vomiting must be ignored as far as 
food changes are concerned, provided the stools shoiw the 
digestion to be normal. One or two stomach washings 
with soda bicarbonate solution may be of assistance, but must 
not be continued. Paraf Javal's preparation of strontium 
bromid ""Iv-xv may be administered one-half hour before 
feeding, four times a day, in a little water. As the age and 
nutrition demand it, the strength of the food should be 
slowly increased, in quantity as well as quality. Advantage 
should be taken of the fact that these babies retain their 
night feeds well by giving them nourishment throughout 
the night, at about three- or four- hour intervals. 

Vomiting is a symptom of summer diarrhea. This is 
almost entirely confined to the bottle-fed. It is impossible 
to enter into a discussion of this chsease at this time, but I 
wish merely to refer to the symptomatic and prognostic im- 
portance of vomiting. Occurring at the ver}^ onset of the 
disease, it results from the direct irritation of the gastric 



VOMITING OF INFANCY. 241 

mucosa, and is benign in character, in that the system is 
saved the absorption of a large amount of fermenting 
material if it were tO' pass through the gut. Occurring con- 
tinuously throughout an attack, or manifesting itself as a 
late feature, it is ominous, resulting from intense toxemia 
and, in the majority of instances, foreshadows a fatal out- 
come. Treatment is unsatisfactory. Lavage to be of value 
must give speedy results, and must not be continued too 
long or be too frequently repeated. A valuable procedure 
is gavage. Not infrequently, when the smallest quantities 
of food are expelled when fed by spoon or bottle, they will 
be retained if given by the stomach-tube. However, care 
and skill must be exercised in feeding by this method 
(Chapter XIII, page 363). The gavage should follow the 
lavage. The food, on the other hand, may be administered 
through the nose (Chapter XIII, page 361). 

Not infrequently all food by mouth must be suspended 
and the infant sustained by small nutrient enemata follow- 
ing colonic lavage. If foods are given by the mouth, they 
must be of the mildest kind and in small bulk, concentrated 
but non-irritating. Cereal-waters or cereal-gruels, egg- 
water, condensed milk diluted 8 or 10 times with a cereal- 
gruel, whey or mutton-broth, are our main reliance. Thirst 
may be allayed by hypodermocylsis or by the Murphy 
treatment. I have seen this give brilliant results in des- 
perate cases. Occasionally hot water dropped upon the 
tongue will stop vomiting. Medicaments are of little value, 
perhaps the best being a small dose of bromid of strontium 
gr. j-ij, or the Paraf Javal preparation just mentioned. 

Vomiting is often a symptom of grave abdominal dis- 
ease. As a rule it here depends upon peritoneal irritation. 
Intussusception is the most frequent condition met in in- 

16 



242 VOMITING. 

fancy, while appendicitis, peritonitis, purulent and tuber- 
cular, occur more often in childhood. The character of the 
vomitus will not infrequently be the concluding point in the 
symptomatology of intussusception, although I have mis- 
taken a fatal purulent peritonitis occurring in an infant i 
week old, as the result of umbilical-cord infection, for in- 
tussusception, on account of constipation and fecal vomiit- 
ing. I have also' seen a small retroperitoneal sarcoma, in an 
infant 6 days old, produce fecal vomiting and bloody stools. 
Vomiting under these circumstances has no' special treat- 
ment, its main importance being diagnostic and its outcome 
depending entirely on the proper surgical treatment of the 
case. 

An important point to be considered in the etiologic 
diagnosis of vomiting in infants is the insidious develop- 
ment of hydrocephalus. This is mentioned tO' put the prac- 
titioner on his guard, as T have on five or six occasions seen 
this error made both by myself and others. 

VOMITING IN OLDER CHILDREN. 

The more common causes for vomiting in older chil- 
dren are the acute infectious diseases, pneumonia, dietary 
indiscretions, zvith or zmthout acute gastritis, acute indiges- 
tion, poisons, acute abdominal disease, uremia, brain dis- 
ease, acidosis ( cyclic vomiting, so called ) , reflex causes, and 
ocular conditions. Vomiting is an important initial symp- 
tom of scarlatina, sjnallpox, meningitis, and less soi of 
measles. It may replace the chill of pneumonia. The 
direct origin of vomiting in these conditions, with the ex- 
ception, perhaps, of meningitis, is toxic. 

By far the vast majority of cases of vomiting in young 
children is due to dietary indiscretions. Included within 



VOMITING IN OLDER CHI LI)U1':.\. 243 

this term are those cases clue to chemical or food 
(ptomaines) poisons, or medicines ingested by accident or 
otherwise. These cases may or may not have the added 
element of gastritis as a causative factor. 

The treatment of this class of cases may be embraced 
within a general plan. The greatest element is prevention. 
It is a grave mistake not to supervise the food of a young 
child up to at least 4 or 5 years, and even after this vigilance 
should not be relaxed. Up tO' the age oi i year, in most 
instances, the infant should receive very litle besides milk, 
and that preferably maternal. A certain amount of latitude 
can perhaps be pennited in this direction, depending upon 
the individual. Many physicians are in the habit of per- 
mitting a certain variety of dried bread called zweiback, at a 
very early age. I have never seen any harm therefrom, but 
in the majority of American children I feel that an exclusive 
milk diet is best, at least up to 9 or 10 months, or until the 
infant has cut several teeth. After this the diet should be 
regulated according to the directions given under Chapter 
III, page 140. 

"Bring up a child in the way it shall go and when it is 
old it wall not depart therefrom" applies to diet as well as 
to morals, and an adherence to a simple diet of wholesome 
foods, with absolute regularity, will prevent as many and 
more cases of vomiting and indigestion as the vicious habit 
of continuous nibbling and overfeeding of improper foods 
will produce. Frequently children are brought to the 
physician by an anxious mother with the tale that they have 
no appetite. Careful inquiry will invariably elicit the his- 
tory that the day is occupied by one continuous meal of 
small quantities of sweets and indigestibles. 

The active treatment, after eliminating^ the cause of this 



244 VOMITING. 

condition, consists in the administration of an ennetic, if toO' 
much time has not elapsed since the ingestion of the sub- 
stance. If the stomach has not been actively irritated or 
mflamed, lavage should be practised. This is a very diffi- 
cult procedure in yonng children and should only be 
employed if urgent. Following this a purgative, preferably 
iced castor oil, or if this is not tolerated, calomel, triturated 
vvell with sugar of milk, should, in small dose, be placed 
dry upon the tongue. Food should be omitted for twenty- 
four hours and, when resumed, should be of the mildest 
kind and given often, but in small quantities. Ice by 
mouth and a mustard paste upon the epigastrium, may be 
of service, while, of medicaments, cocaine gr. ^/go, bismuth 
gr. X, and strontium bromide gr. iij are the best. 

In acute abdominal disease, especially in appendicitis 
and in peritonitis, as mentioned before, the interest attached 
to vomiting is purely academic and diagnostic. In' peri- 
tonitis the vomitus may become fecal in rare instances and 
indicates a fatal outcome. Rarely these cases are benefited 
by extensive lavag-e. 

The insidious onset of nephritis and uremia is often 
announced by an unexpected attack of nausea and vomiting. 
This is especially true when occurring during the third or 
fourth week of an attack of scarlet fever, and such an 
occurrence should always lead to a urinary analysis. In 
this disease, therefore, vomiting becomes a symptom of 
much diagnostic import. Its treatment consists in the 
treatment of the underlying cause and is entirely elimina- 
tive, this being accomplished by diaphoresis, diuresis, and 
catharsis. 

Vomiting when associated with or rather due tO' brain 
disease, especially tumor, abscess, meningitis, less often 



VOMITING IN OLDER CHILDREN. 245 



()- 



hydrocephalus, is also oif diagnostic importance. It is pr 
jectile in character and occurs without nausea. There is 
no special treatment. 

Of greater interest, perhaps, than all these, in that it is 
peculiarly a condition of childhood, is periodic or so-called 
cyclic z'omiting. Children, apparently otherwise well, but 
of delicate mold, the former subjects of scurvy, marasmus 
or rickets perhaps, without any apparent cause, certainly 
without any indiscretion in diet, are seized with severe 
attacks of vomiting. First the stomach contents are ejected 
and then, w'ith severe straining and retching, a large 
quantity of bile-stained material is throiwn off. There may 
or may not be associated fever. Usually, however, the 
tempierature does not go much higher than ioo° F. 
Jaundice does not occur, but the skin becomes muddy. 
Soon the attack ceases spoaitaneoiisly and the child is as 
well as ever and hungry, and remains so until the next 
attack occurs within a few weeks. Preceding the attacks 
the child becomes languid, pale, loses interest in its play, 
and has dark rings under its eyes. By these signs the care- 
taker can, if observant, foretell an attack by tv^nty-four 
hours. These children are usually anemic, have a hemo^ 
globin percentage of below 60, and are sometimes the sub- 
jects of purpura. There is usually a slight leucocytosis up 
to 15,000. The etiology of this interesting condition is 
obscure, although the researches oi Edsall and others would 
point tO' an acidosis or an acidemia. Many of these cases 
present a highly acid urine containing large amounts ' of 
acetone, diacetic and oxybutyric acids. 

Treatmient is unsatisfactory. The attack is self-limited 
and remedial measures are of no avail. Between attacks 
all efforts should be directed toward building up the general 



246 VOMITING. 

strength, improving the nutrition, and overcoming the 
acidosis. With this end in view the diet should contain 
starches and only a moderatei amount of protein. Digest- 
ants should be given if needed, and large doses of sodium 
bicarbonate over a long period of time are regarded as 
specific by Edsall and do good in many cases as a preventive. 
Iron citrate or sodium cacodylate, alone or combined, and 
administered hypodermically, may be useful in combating 
anemia. 

Reference has elsewhere been made tO' those cases of 
periodic vomiting* which are not due toi acidosis, but which 
depend upon pylorospasm, which originally developed in 
infancy and which has not entirely Vecovered. These cases 
can be recognized if sought and especially if they are 
studied by the X-ray (Chapter XII). 



CHAPTER VIII. 

CONSTIPATION. 

This will be discussed largely from the standpoint of 
treatment. The term itself is more or less( comparative. 
The movements may be sufficiently frequent but small in 
bulk. They may be both sufficiently frequent and of nor- 
mal bulk, but too dry in consistency. When constipation is 
complete it is said to be obstipation. This usually depends 
upon an organic basis. An intelligent therapy can only be 
arranged after considering the etiology in some detail. 

ETIOLOGY. 

Two factors are operative more or less in nearly every 
case of costiveness, viz., diet and habit. This is true of 
infants as well as of children. Many babies are made 
constipated because the caretakers do not give them an 
opportunity to evacuate their bowels spontaneously. This 
results in the routine administration of drastic purgatives 
and local irritants, as suppositories and injections. The 
bowels shortly cannot empty them(Selves unless they are so 
stimulated. 

A diet poor in sugar and fat or one rich in protebi is 
particularly harmful in this respect. Food which is com- 
pletely digested alsoi predisposes. 

Habit is especially potent in older children. The re- 
sponse to nature's call is delayed, with the result that atony 
of the bowel and gaseous distention ensue. In cases of 
rickets in w^hich the involuntary musculature of the small 

(247) 



248 CONSTIPATION. 

intestines is decidedly at fault, this state of affairs also 
exists. 

Constipation in the Breast-fed. — ^A great many mothers 
complain that their babies are constipated. I find in most 
instances that these women do! not give their children a 
chance to move their bowels naturally. They proceed to 
administer purgatives and injections very early, usually as 
soon as the infant exhibits a little colic. Most of these 
babies consequently do become constipated from such treat- 
ment. If the mothers are reassured and are instructed to 
leave the babies severely alone, the fear of constipation 
speedily passes, as soon as a few natural evacuations occur. 
Occasionally, before the habit is fully re:-established, use 
may be made of a glycerin suppository. This treatment 
must not be continued over too' great a .period of time, for 
the fear of establishing the habit. It is only employed to 
help out, and not more than once or twice a week. I always 
advise the mother tO' allotw her infant to go thirty-six hours 
before she attempts to bring about a movement. Usually 
before this period of time has elapsed, a spontaneous evacu- 
ation will have taken place. 

At times something may be accomplished by a milk 
analysis and by attempting through the mother's diet to so 
influence the composition of her milk as to make up for the 
visible deficiency. Thus, the amount of sugar, fat, and 
protein may be varied according to^ the directions already 
given under Chapter I, page 35. While, of course, quick 
results cannot be expected from this method alone, it should 
always be pursued as a very important adjuvant. 

It is often of service to^ administer to these babies, just 
before feeding, a small quantity of either oatmeal or 



/ ^ 

ETIOLOGY. 249 

Granum water. Between feeding, under any circumstances, 
boiled water should routinely b€ offered to all breast babies. 
Constipation in Artificially Reared Infants. — Constipa- 
tion is not uncommon in this type of baby. The stools are 
often hard, dry, and crumbly (Plate VIII), and are expelled 
by the infant with great straining. Much may be accom- 
plished by dietetic manipulation. I find it to be of great 
service to change the diluent of the milk to oatmeal-water. 
This is especially effective if barley-water or a wheat-flour 
gruel has been employed previously. In some other cases, 
where the formula has been boiled, feeding it raw will cor- 
rect the trouble. Hardly to be recommended as a routine 
procedure and yet decidedly effective, is the feeding of the 
formula cold instead of warm. In other cases the result is 
favorably influenced by increasing the amount of food if 
this has been found tO' be unusually small in bulk. I have 
noted instances wherein the concentration oi the food was 
insufficient, i.e., the amount of diluent was greater than the 
digestive powers of the infant demanded, and entirely too 
great to permit a sufficient residue to provide for the neces- 
sary normal peristaltic stimulus. Thus a very low protein 
may be responsible for constipation. On the other hand a 
very high percentage of protein, especially if the formula 
be weak in fat and sugar and if the protein be highly com- 
minuted, as in eiweissmilch or in buttermilk, or if the pro- 
tein be otherwise influenced, as chemically by pancreatiza- 
tion or by boiling, may cause constipation with hard, dry 
stools. Unchanged coagulable cow-protein, on the other 
hand, when fed in excessive quantities, may cause diarrhea 
on account of the irritant effect of the undigested masses 
which result. In these instances a starchy diluent, as bar- 
ley-water or a thin, well-cooked wheat-flour water, is of 



250 CONSTIPATION. 

service in checking the diarrhea. The curd may also be 
influenced by boiling, pancreatization, or by the other 
methods detailed under Protein Intolerance (Chapter II, 
page io6). 

Infants whose formulas are especially weak in fat are 
commonly constipated, and the condition can be favorably 
influenced by the addition of cream in gradually increasing 
amounts. Care, however, must be exercised not to exceed 
3^ toi 4 per cent, (even this may be too much for certain 
individuals), othenvise fat intolerance may ensue, with the 
discouraging evidences of weight disturbance. 

Not all cases are benefited by increasing the fat. Some 
are made zvorse, especially if the fat be split up intO' fatty 
acids, which in the presence of lime-salts causes the for- 
mation of calcium-soiap stools, which are constipated (Plate 
VII). Excessive fat may cause the formation of a greasy, 
foul-smelling, constipated stool (Plate VI). These stools 
contain much fatty acid and often present the odor of 
overripe cheese. Lime-water should therefore, unless it be 
used fotr a special indication, as hyperacidity, rarely enter 
into the composition of any formula. Personally I have 
practically discarded it for years, and have not felt the 
necessity of employing it in any instance except, very occa- 
sionally, in cases of pyloric obstruction. These cases of 
constipation due to an excess of fat are benefited by diminish- 
ing the fat or by predigesting it (pancreatization). 

Constipation in the bottle-fed is often materially im- 
proved by increasing the amount of sugar or by changing 
from milk-sugar to cane-sugar oi", still better, to some of the 
malt preparations, as Dextri-Maltose. The effects of low fat 
and of low protein, even though the sugar be high, are 
seen in babies fed upon condensed milk. Many of them 



ETIOLOGY. 251 

suffer from constipation. The ideal for which tO' strive is 
a food coimbination in which all the elemnets (fat, protein, 
and sugar) are reasonably represented and in which no- one 
element far exceeds the others. This will not only insure 
a normal state of the intestinal juices, but will provide a 
proper nutritional balance. Elsewhere I have stated that 
almost routinely I employ cane-sugar to provide extra car- 
bohydrate. These cases of constipation constitute one of 
the exceptions in which I make use of one of the malt 
preparations. 

A diet rich in starch is constipating. In fact, this is not 
at all a bad way in which to favorably influence a state of 
diarrhea. Many of the patented foods are constipating. 
The milk diluent may contain too much starch. I have seen 
constipation result, too', from the use of buttermilk into 
which an excess of wheat-flour had been incorporated. 
Therefore the starch must be reduced and the diluent made 
weaker. In some instances favorable influences are noted 
where the diluent is dextrinized after the method of Chapin, 
who adds some diastatic agent, as cereo' (glycerite of dias- 
tase) or a dram or two- of one of the many malt preparations 
upon the market. 

In yet other infants, good results are obtained by 
changing the diluent completely to oatmeal-water. This is 
quite laxative in its eft'ect and should in all cases be tried. 
Many babies will show surprisingly good results from the 
use of this simple maneuver by itself. 

Fruit- juices serve an admirable purpose in the bottle- 
fed, not only on account of their antiscorbutic effect, but 
also for their influence upon the stools. I prefer prune- 
juice made by boiling a pound of prunes in a quart of water 
without sugar. This is palatable, antiscorbutic, and laxa- 



252 CONSTIPATION. 

tive. Usually from 2 to 3 teaspoonfuls are given once or 
twice a day on an empty stomach. Other juices, as of the 
orange, grape, apple, etc., may be employed. 

A broth made from vegetables (Chapter III, page 146) 
is useful in this connection and may be given ad libitum. 

As the infant grows older and articles other than milk 
are added to the diet, other things being equal, the tendency 
toward constipation is often materially lessened. Therefore, 
if digestive disturbances are absent and two- or' three teeth 
have been erupted, such foods as oatmeal, Graham crackers, 
whole- wheat bread, and tender vegetables may pro^x to be 
eminently useful. Scra,ped apple may also' be fed in tea- 
spoonful doses once or twice daily. 

From earliest infancy the habit of regular evacuations 
should be established. The infant's buttocks are brought 
into contact with a small chamber at definite inten-als dur- 
ing the day. As soon as the baby can sit up it should be 
placed in a chair in the same regular way. Later the habit 
of having a daily bowel movement should be made an 
object of pride on the part of the child, who should be early 
taught that nothing must be permitted to interfere with its 
response tO' nature's demands. Rewards, if necessary, 
should be oiffered to encourage this, and mild punishment 
inflicted for failure to obey. 

Older Children. — Children must be taught to crave 
wholesome food. It is just as easy to do' this as it is to 
allow them, to crave those foods which cause digestive and 
metabolic disturbances. Vegetables in abundance are not 
only wholesome, but laxativei in their effects. Stewed and 
seasonable, raw, ripe fruits are valuable adjuncts, . but 
apples must be scraped or very thoroughly chewed. \A^ell- 
cooked coarse-grained cereals, especially oatmeal, are valu- 



ETIOLOGY. 



253 



able. Cereals whicii are eaten uncooked, with milk and 
sugar, are not to l)e recommended. An abundance of 




Fig. 44. — Constipation due to dilated colon (Hirschsprung's disease). 



butter and olive oil, if they cause no digestive or metabolic 
disturbances, is valuable. 



254 CONSTIPATION. 

Sweets and meats are constipating and, therefore, they 
are to be largely curtailed. I have, however, met instances 
wherein diet has no influence at all in relieving the condi- 
tion. One patient, a little boy, recently came under my 
observation, who consumed seven or eight apples a day 
without any effect whatever upon his stools. Such obstinate 
instances require the use of drugs. 

MEDICINAL TREATMENT. 

Where dietary measures fail, the cause of the consti- 
pation probably depends upon functional atony or upon 
anatomical twists, kinks or tortuosities or upon congenital 
dilatation of the colon (Fig. 44). In addition to drugs 
miechanical manipulation, which will be discussed later, is 
often valuable. To- rehearse the entire list of purgatives 
would be time-consuming and useless. I shall only mention 
those agents which have been useful in my own experience. 

I have obtained very encouraging results from the use 
of some form of Russian mineral oil. I have employed 
the preparation known as Interol or Rusol, marketed by 
Van Horn & Sawtell, or Squibb' s preparation, or Olo. They 
all act the same and one is as good as the other. This is 
true as well of the American mineral oils to be found upon 
the market. These oils are not digested. They are passed 
as they are taken. They simply lubricate the intestinal wall 
and cause the contents to slip along easily. They have the 
great advantage of being tasteless. They are administered 
from a spoon or placed upon a, little water which the child 
drinks without knowing that the oil has been added. A 
very small amount of sugar may be added for fastidious 
children, and the dose offered to them^ as "sugar-water." 
Infants receive from i tO' 2 fluidrams once or twice a day, on 



MEDICINAL TREATMENT. 255 

an empty stomach. Older children are given about half an 
onnce. The idea is to administer just enough tO' secure the 
proper lubrication which will insure from one to three 
movements daily. There are no ill-effects. Nor is there 
any danger of establishing a habit. The only inconve- 
nience noted is that the oil will leak through the anus and 
so'il the clothing, if too much is taken. There is no relaxing 
efifect upon the bo-wels, and of all permanent agents to be 
employed foir the relief of constipation I firmly believe that 
one or another of these preparations is by far the best. 

Olive Oil. — This may also be classed as one of the valu- 
able semimedicinal agents. It is administered per oram or 
per rectum. It also possesses valuable food qualities, and is 
especially useful in marantic children of over i year of age. 
By mouth from J^ fluidram to 2 fluidrams are administered 
t. i. d. after meals. It is often more readily accepted if 
given with grape-juice. It rarely disturbs the digestion. 
It must then be given per rectum. By this method valuable 
results are commonly obtained if the remedy is properly 
administered and continued over a sufficiently long time. 
Three to four ounces of the oil are deposited high into the 
bowel each evening, or every other evening, as the infant is 
put to bed for the night. A soft-rubber catheter is anointed 
and gently passed into the bowel for a distance of about 
eight inches. An ordinary small, infant's, hand rectal 
syringe is now filled with the warm oil, and the hard- 
rubber tip is connected with the free distal end of the 
catheter, and the contents of the rubber bulb are gently cotm- 
pressed through the catheter into the intestine. One or 
two syringefuls are sufficient (Chapter XIII, Fig. 56, B). 
The baby is diapered and usually, the next morning, there 
wnll be found a substantial movement. In some cases this 



256 CONSTIPATION. 

occurs immiediately. Gradually the frequency of these in- 
jections may be lessened if the movements show a tendency 
toward becoming spontaneous, as they frequently do'. This 
treatment is also valuable in older children, a little more oil 
being" employed as well as a slightly thicker catheter, which 
may be inserted about ten or twelve inches. 

Agar-agar as such, of employed as Regulin after the 
method of Prof. Dr. Otto Schmidt,, is useful in some cases. 
It acts by absorbing moisture through the intestinal mucosa 
and thereby, as the agar-agar swells, increases not only the 
bulk of the intestinal contents, but makes themi more liquid. 
As a rule I prefer the ordinarily powdered agar-agar as 
purchased in the shops, to the Regulin, as it is tasteless, the 
latter being impregnated with cascara sagrada, which makes 
it bitter. Either, however, is administered in stewed fruit 
or cereal in i- or 2- dram doses once oir twice daily. The 
results are not always satisfactory, although in some cases 
decided benefit is experienced. The material must be 
mixed with the food during the child's absence. 

Milk of Magnesia. — This in no sense cures constipation. 
It is, however, often of value in assisting, especially the 
bottle baby, across a troublesome period. Thus, until the 
proper-strength formula is found, many infants are con- 
stipated. Often, as previously stated, the condition is 
remedied by changing the diluent to oatmeal-water. Until 
this is done or has a chance tO' act,, 15 to. 20 tos 30 or more 
drops of Philip's Milk of Magnesia are added to each 
bottle or tO' every other bottle, or, perhaps, but once or twice 
a day, according to effect. The dosage, both in amount 
and in frequency, is gradually reduced tO' a nicety — simply 
to obtain the desired result. It may also be given tO' breast- 
fed babies. It is finally omitted. 



MEDICINAL TREATMENT. 257 

Castor Oil is mentioned simply to impress upon the 
mind of the student that, while it causes looseness of the 
bowels, it must never be considered as a remedy to cure 
constipation. When indicated it is one of the best remedies 
in the treatment of diarrhea. Its secondary effect is relax- 
ing and constipating. It is simply employed to effectively 
sweep out the intestinal tract. To this it owes its use in 
diarrhea and also in cases of constipation where the bowels 
have not moved for several days and it is desired tO' cleanse 
the intestines and to relieve acute or chronic toxemia. Its 
use must always be followed by tonic laxatives, of which 

Cascara Sagrada is the best example. The great objec- 
tion to it, however, is its taste. This may be more or less 
disguised by employing the aromatic fluidextract in doses 
ranging from 15 to 45 drops once or thrice daily. Or it 
may be disguised as follows: — 

I^ Liquid extract of cascara (B. P.), 
Liquid extract of liquorice (B. P.), 
Syrup of orange-peel, 
Chloroform-water .aa nixv. 

Or as follows : — 

IJ Sodium sulphate gr. v. 

Liquid extract of cascara (B. P.) miiss. 

Glycerin viiv. 

Cinnamon-water q, s. 

I have seen the good eft'ect of both of these formulas in the 
wards and in the out-patient department of the Hospital 
for Sick Children, Great Ormond Street, London. The 
latter prescription is slightly more stimulating than the 
foimier. Through experience in the same institution I have 
obtained good results from the following combination of 
tonic laxatives: — 

17 



258 COXSTIPATION. 

I^ Tr. nucis vomicae ttl ss. 

Tr. zingiberis iTtij. 

Tr. hj'Oscyami rrtv. 

Tr. aloes irt iv. 

Syriipi sennas nixv. 

Dill-water (B. P.) q. s. 

This is carminative as well as laxative. A small quantity 
of the fluidextract of cascara could readily be added with 
advantage. 

Phenolphthalein is a useful laxative in some cases. It is 
found upon the market in various pleasant combinations 
with other laxatives, or alone. The dose varies from ^ to 
2 grains. 




Fig. 45. — Massage balls used by the author in the treatment 
of constipation. (Physician's Supply Co., of Phila.) 

MECHANICAL TREATMENT. 

No case of constipation is properly handled unless 
mechanical means have been given a trial. Of these 
abdominal massage is of considerable value. In my own 
experience this is best accomplished by the systematic em- 
ployment of a massage ball (Fig. 45). It is made in sizes 
Nos. I, 2, and 3. They consist of iron covered with leather 
and weigh, respectively, ^ lb., ij4 lbs., and 2 lbs. They 
resemble baseballs. They are made for me by the Physi- 
cian's Supply Company, of Philadelphia. The size of the 
ball is selected according to the age and size of the patient. 



SPONDYLOTHERAPY. 259 

No. I is for infants, No. 2 is for children from ij/^ to 2 
years of age, and No. 3 for older children. Morning and 
evening, before the child arises and before it retires, the 
bladder being at first emptied, the ball is rolled by the palm 
of the hand in a circular motion, slight pressure being used 
in addition to the weight of the ball, along the course of the 
colon, up the right side, across and down the left. This is 
continued for from ten to fifteen minutes, after which a cir- 
cular motion is continued for five minutes over the center 
of the abdomen, over the small intestines. I find that many 
babies are benefited to nO' small degree. The treatment 
must continue for tw^o or three months. 

SPONDYLOTHERAPY. 

Albert Abrams, of San Francisco, recommends that in 
atonic constipation, the most common variety, concussion 
or sinusoidilization of the spines of the first three lumbar 
vertebrae be practised daily, and in the spastic variety the 
same treatment be applied to the spine of the last dorsal 
vertebra. If the exact nature of the constipation cannot be 
determined, alternate concussion of these areas is practised 
at the same sitting. Concussion may be practised by placing 
a piece of linoleum about j4-ii^ch thick over the spine. This 
is then struck light but rapid blows with an ordinary tack- 
hammer. In lieu of this the middle-finger of the left hand 
may be placed upon the spine and struck with the closed 
fist of the right hand, which acts as the plexor or concussor. 



CHAPTER IX. 

DIARRHEA. 

This affection will be considered largely in its relation 
to the suckling. Therefore, treatment will be discussed 
mainly from the standpoint of the breast-fed and the baby 
fed upon cows' milk. 

The splitting up of the fat of the food sets free fatty 
acids. These normally combine with the alkaline bases of 
the food and of the intestinal mucus. If these acids be in 
excess they not only irritate the intestinal mucosa, causing 
increased peristalsis and an increase in the intestinal mucus, 
but also cause the intestinal contents to be acid. This acidity 
favors the development of certain bacteria which require 
an acid medium. These bring about destruction of the 
carbohydrate. This destruction of the carbohydrate is 
called fermentation, which is distinctly an acid-producing 
process, and this still further favors the development of acid- 
producing bacteria and the development of diarrhea. 

Destruction of protein is called; decomposition and 
results in the fo^rmation of alkalies. The alkaline medium 
favors the development of the bacteria of decomposition. 

Thus, the interaction between certain food elements and 
bacteria results in either fermentation or decomposition. 
In health, within the intestines, each process is proceeding 
simultaneously. The feces, or the intestinal contents, will 
be neutral, or slightly alkaline o^r slightly acid. Neither 
alkalinity nor acidity can preponderate, the one over the 
other, tO' any great degree without resulting* in a disturbance 
(260) 



DIARRHEA. 261 

of the circulation of the intestinal mucosa. This results in 
the pO'Uring out oif an excess of mucus and in an increase in 
the peristaltic action — diarrhea; although the effects of 
excessive acidity are more quickly noted than are thosei of 
an excess of alkalinity. This, and also- the fact that the 
presence of mucus indicates an attempt on the part of 
nature to protect the lining membrane and tO' neutralize 
the acid — for hitestinal mucus is alkaline — have an impor- 
tant therapeutic significance, as we shall see. 

From the preceding it follows that in most cases of 
diarrhea the stools are acid because ferineniation is more 
common than decomposition. Even in the presence of de- 
composition the irritant effects of the alkaline medium, is 
less. The continuous outpouring oif large quantities of 
mucus causes the infant's nutrition to become seriously 
impaired because of the loss of great quantities of water 
and of salts, these being the main constituents of mucus. 

It has been seen hOiW the reaction of the intestinal con- 
tents determines the nature of the preponderating variety 
of bacteria, and how this reaction depends primarily upon 
the nature of the food, i.e., that there is a reciprocal rela^ 
tionship existing hetiveen the food and bacteria and that 
each is necessary to the other in order to carry on the 
processes of intestinal digestion. It is also' understood now 
that the character of the food readily determines the nature 
of the bacteria. 

It may, therefore, correctly be stated that the nature 
of the food which is given to an infant determines largely 
the presence or the absence of diarrhea, and that the food 
assumes at once the dual role of etiologic factor and prime 
therapeutic agent. Clinically this has been proven tO' be a 
fact, and most cases of diarrhea in both the breast- and in 



262 DIARRHEA. 

the bottle- fed will yield, if not neglected too long, nicely to 
dietetic management alone and without the use of drugs. 

SYMPTOMS. 

As stated, the intestinal contents are more fluid, usually 
more acid (sometimes more alkaline), and the peristalsis of 
the gut is accentuated; therefore the bowels move more 
frequently. At first there may appear but very little change 
in the physical appearance of the discharges, aside from 
their thinner consistency. Shortly, however, an excess oif 
mucus is noted. This is, as a rule, very stringy, yet withal 
intimately mixed with the stool. The latter is at first 
yellow,, then yellow and green, and finally may assume a 
grass-green appearance, or it may be yellow-and-green 
mixed. The green color is due to biliverdin, an oxidation 
product O'f bilirubin (Plates IV and V). It must not be 
forgotten that the color of a stool must be noted' as soon as 
it is passed, because all stools, especially those of sucklings, 
turn green an hour or so after being exposed tO' the atmos- 
phere. If the process continues the mucus may be blood- 
streaked or a fair amount of blood may be mixed with the 
stools (Plate X). If this has originated high up in the 
bowel it will be dark ; if low down it will appear bright and 
may not be as well mixed. As the case progresses the fecal 
character of the movements may be lost entirely, it consist- 
ing simply of a colorless discharge of water or mucus. 
These stools are odorless as a rule, and are seen commonly 
in "summer diarrhea" (intoxication) and are of serious 
import. 

The odor of the stool assists in determining the nature 
of the process existing within the intestine. In cases of 
fermentation the odor is distinctly sour and acid, but not 



SYMPTOMS. 263 

unpleasant. In cases of decomposition, on the other hand, 
the reverse is true, the discharges being foid-smelling. 
Tlie reaction may be readily tested with litmus-paper. 
Further, if the stools are intensely acid their constant exit 
from the anus is associated with severe excoriation of the 
skin about the buttocks and the anal region. These cases 
are particularly common in babies who cannot digest the 
sugar of their mother's milk, and in bottle-fed babies who 
are suffering from sugar intolerance. 

In cases due to an excess of fat, nature attempts to cor- 
rect the acidity by causing the free fatty acids to combine 
with the alkaline salts which are contained in the excess of 
intestinal mucus. The action is called saponification, and 
results in the discharge of stools containing large or small, 
hard, granular masses of calcium soap (Plate VII). These 
masses are contained in a liquid matrix of mucus. Their 
presence in constipation has also been noted (Chapter 
VIII). In these instances all the fatty acids have been 
neutralized by the alkaline (calcium) bases contained in the 
mucus — the soi-called soap stool (Plate VII). These cases 
also, in addition, usually exhibit an alkaline, ammoniacal 
urine. 

The stools commonly contain white particles or masses, 
as well as mucus. Much time and discussion have been 
wasted in an effort to determine the exact nature of these. 
Are they constantly protein or constantly fat? Latter-day 
pediatrists contend that they are always fat ; that undigested 
protein never is pathologic. With this view I cannot be 
in accord. Unchanged cows' curd (unchanged chemically 
or physically) is as indigestible today as it was twenty 
years ago, and may and does in many instances, by its 
directly irritating effect, produce diarrhea (Chapter II). 



264 DIARRHEA. 

Therefore the answer fairly made is that these white masses 
may be either protein or fat, and that this can be determined 
in the individual case by the proper test elsewhere 
described (Chapter II). The stools appear often, under 
these circum.stances, not unlike loosely scrambled eggs 
(Plate IV). 

Constitutional Features. — No infant can have diarrhea 
without suffering as toi its nutrition. These babies all lose 
weight — more or less according tO' the severity and duration 
of the process. Thus, in acutely severe cases the loss of a 
pound or two in twenty-four hours has been recorded. In 
less severe, but equally obstinate subacute or chronic, cases 
this amount of weight may be lost within a period of a 
week or* two. The loss is due directly to' the loss of water. 
The tissues become dehydrated. Fat consists largely of 
water. Therefore the plumpness and the roundness of the 
babe are speedily altered. The tissues are also' quickly 
demineralised. Consequently, nervous irritability may in- 
dicate its presence by a positive Chvostek reaction or 
increased electrical reactions (vide Spasmophilia, Chapter 
X, page 276). 

In cases of dyspepsia and of intoxication, fever develops. 
In the former the range is not so high — from 100° to 
101° F. per rectum, while in the latter it may register from 
104° to 106° F. and the symptoms of intense intoxication 
may appear. These are: collapse, shallow breathing, 
sunken eyeballs, sharp features, cold nose, coma, ashen hue 
about the nose and mouth, albuminuria, glycosuria, rapid 
and thready pulse, vomiting at times, together with fre- 
quent watery evacuations and a tremendous loss in weight 
(vide Sugar Intolerance, Chapter II, page 113). 



SYMPTOMS. 265 

Diarrhea or Intestinal Indigestion in the Breast-fed. — 
Here one meets a colicky, breast baby, suffering from 
gaseous distention and diarrhea with yellow or greenish- 
yellow, loose stools containing stringy mucus and finely 
chopped up white particles (Plate V). These stools have 
a slightly pungent, acid, not unpleasant odor. These babies 
have excoriated anal regions and frequently spit up after 
feeding. In many the skin is somewhat irritated or there 
may be present a papular eruption all over the body, or it 
may be confined to the face. These infants rest poorly and 
yet, in spite of their discomforts and abdominal objective 
features, many of them continue to gain weight. They are a 
source of worry to the young mother and of endless annoy- 
ance to the physican, because it is difficult for him to 
appease the mother with the statement that the infant is all 
right when she and her friends think that it is all wrong. 
These cases, in my judgment, are only precarious in so far 
that they, more than any other, are speedily taken from the 
breast because the average physician does not understand 
how to treat them, because the mother demands that some- 
thing must be done, and because that ''something" usually 
consists in removing the infant from the breast and putting 
it upon some indifferently modified formula, instead of at- 
tempting to treat it rationally through the mother s milk. 
From, this point, in many cases, is marked the beginning of a 
downward course — the feeding of many and varied milk 
mixtures and patented foods, ending in further digestive 
disturbances, nutritiomal disorders, entire food intolerance, 
and death. Thus I believe that this stool is largely, though 
indirectly, responsible for the vast infant morbidity and 
mortality occurring during the first year of life. 



266 DIARRHEA. 

TREATMENT. 

Breast Babies. — In the cases just cited the maternal 
milk should be analyzed. If this be impossible it must be 
assumed that the milk contains too much fat or too much 
sugar or both for the indimdual. An attempt must be made 
to readjust these through the mother's diet and through 
exercise according to the methods described on page 35, 
Chapter I. 

It is primarily important to reassure the mother re- 
peatedly. If maternal mental quietude can be secured the 
digestion of the infant will be materially assisted. The 
baby must be weighed thrice weekly in the presence! of the 
mother, who must be made to realize the desire of the 
physician to deal honestly with her. This instance is an 
exception to the rule against toO' frequent weighing. At 
the same time the mother must be assured that, as long as 
her baby gains, not very much can be wrong. If once 
maternal control is secured the problem will be easy, for 
not infrequently weeks and even months are consumed be- 
fore the stools become normal in these babies, and some- 
times they never do so until weaning is accomplished. For 
a while the stools may appear quite normal,, when they 
again relapse. The suggestion of Dr. Frank Neff, of Kan- 
sas City, Mo., that the maternal milk be drawn and skimmed, 
I consider a good one, though no-t always practical. 

If vomiting occurs the feeding interval must be length- 
ened toi twO' and one-half tO' three hours and even to four 
hours. The infant must not be kept at the breast too long 
— from five tO' fifteen minutes being suificient. Nor must it 
receive its meal too fast. The mother can control the flow 
of milk by making pressure upon the nipple. The infant 
must not be permitted toi suck air, and after each feeding it 



TREATMENT. 267 

is held erect and its abdomen gently compressed in order to 
assist in the easy expulsio-n of gas. Many of these babies 
are benefited by instituting a "hunger period" for twenty- 
four hours, during which time only weak tea sweetened 
with saccharin, or barley-water, is given, or by giving them 
just before nursing a half-ounce or so of plain boiled water 
or, preferably, thin barle}^- water. This dilutes the mother's 
milk, assists in dividing up the curd, and often causes the 
stools to become normal, at least for the time being. A 
carminative water, as peppermint-water, anise-seed water, 
soda-mint water, or dill-water, may be useful in either pre- 
venting or curing the colic. A peaceful night may be 
secured for the entire hoiusehold by giving the infant a bath, 
the temperature o^f which shoiuld be between ioo° and 
iio° F. 

Medicinal. — Occasionally a dose of from i toi 3 drams 
of castor oil in connection with a twenty-four hour ''hunger 
period" may, if associated with energetic dietetic treatment 
of the mother, cut short an attack. I have an impression, 
growing stronger with increasing experience, that physi- 
cians too readily administer purgatives, especially calomel 
and castor oil, in cases of diarrhea occurring in sucklings. 
It is true that the purgative sweeps the intestinal tract of 
the offending substance, but it is, in addition, itself 
decidedly irritating and may continue the digestive disturb- 
ance for some time before it itself is entirely* eliminated 
from the gut. Consequently it takes a considerable time 
before the relaxed and irritated bowel regains its tone. 
The danger from this state of affairs is not so' menacing in 
the breast-fed as in the bottle-fed, for the irritant effect of 
the purgative may be all that is required to induce a food 
intolerance, the consequences of which may be far-reaching 



268 DIARRHEA. 

and even fatal. The ''hunger period" would appear to be 
sufficient, meanwhile permitting the diarrhea toi cure itself, 
i.e., allowing the irritating substance in the food, which 
causes the disturbance, tO' act as the purgative, the bowel 
thus ridding itself of the offending material without the 
assistance of other irritants. Of the two, calomel and cas- 
tor oil, the oil is to be preferred as the least irritating. 
Should the diarrhea continue longer than appears necessary 
after the withdrawal of the food, and should the toxic 
symptoms persist in their intensity or be unusually severe at 
the outset, then a sufficient dose of oil may be administered, 
but it must not be repeated. Thug it would appear best to 
advise that all purgatives should, in sucklings suffering with 
diarrhea, be administered with caution and only after 
mature judgment. 

The following may be administered with excellent effect 
just before or immediately after food. It may be given 
in barley-water or in plain water: — 

B Extract pancreatin, 

Taka-diastase aa gr. ij. 

Pul. aromat., 

Sac. albse aa gr. iij. 

M. et ft. chart, no. j. Mitte no. xij. 
Sig. : As above directed. 

Especially, if combined with a hot bath, sodium bromid 
will often soothe the babe tO' peaceful slumber : — 

I^ Sodii bromidi gr. xxxij. 

Tr. opii camph., 

Aquae menthse pip., or 

Aquae anisi Biss. 

Syr. simplicis q. s. ad f Sij. 

M. ft. sol. 

Sig. : As above directed or f 3j t. i. d. or p. r. n. in aqua. 



TREATMENT. 269 

Bismuth and intestinal antiseptics play no part in the 
treatment of diarrhea. 

Should no improvement occur the infant must l>e re- 
mo'ved from the breast and placed upon eiweissmilch or 
upon buttermilk-and-flour mixture sweetened with sac- 
charin. Meanwhile thel breast function is maintained by 
the systematic use of the breast-pump. When the stools 
again become normal the infant is again placed upon 
maternal milk. If, however, one or more relapses ensue, 
suitable artificial feeding must be instituted. 

Treatment in the Bottle-fed. — This too is largely die- 
tetic. The following routine has many times yielded good 
results : An initial purgative of castor oil may or may not 
be administered, in keeping with the ideas just discussed. 
Calomel I have abandoned, as its action is too^ slowly 
inaugTirated ; because it is toO' irritating,, and also' because 
its effect may be constipating and it must therefore be 
supplemented by castor oil. A ''hunger period" of from 
twenty-four to thirty-six hours is instituted. The infant 
receives nothing but weak tea sweetened with saccharin 
(i gr. to the quart) or barly-water salted to taste and 
sweetened in a similar manner. Finkelstein's eiweissmilch, 
also sweetened with saccharin if necessary, is now ad- 
ministered. However, in many instances eiweissmilch is 
not available in America. I then make use of the Blockley 
buttermilk mixture, omitting the sugar and sweetening 
with saccharin if the infant rejects it unsweetened (Chapter 
III, page 124). This is practically eiweissmilch except that 
it does not contain the curd of an extra litre of milk. It is, 
like eiweissmilch, poor in fat, poor in sugar, and rich in 
protein, w^hich is finely comminuted. It is sterile. It thus 
provides all that eiweissmilch does and, in addition, it 



270 DIARRHEA. 

contains ccwDked wheat-flour, the starch^ of which is very 
valuable in these cases. Furthermore it is much cheaper 
and very easily made. Instead of either the eiweissmilch 
or the buttermilk, Larosan makes a very useful substitute. 
This is highly recommended by Prof. Dr. Wilhelm Stoeltz- 
ner (Halle), its originator. It is a calcium casein in 
powder form. It is a light, dry powder, and is very cheap. 
This preparation is indicated in all the acute and chronic 
dyspepsias. It is commonly employed by adding ^/g ounce 
to I pint of milk and i pint of diluent. In weak, debilitated 
children ^/g quart of milk and ^/g quart of diluent may be 
employed with ^/g ounce of Larosan. In older children ^/g 
ounce of Larosan may be added to i quart of whole milk. 
The effect of this substance, according to Stoeltzner, upon 
the character of the stools, is often shown within twenty- 
four hours. Personal experience with this substance has 
been satisfactory in a dozen or so cases. 

Shortly after the use of any one of these preparations, 
if the case be not too severe and if it progresses favorably, 
the stools will become thick and present a characteristic 
dry, crumbly, brownish-yellow appearance. This is the 
typical eiweiss stool. It consists largely of calcium soap. 
Its incidence is ahvays a valuable and favorable sign. 
These preparations are continued fori some days. Grad- 
ually carbohydrate is added in the form of either cane-sugar 
or one of the preparations of maltose, as Mead-Johnson's 
Dextri-Maltose, Loeflund's Food Maltose, or Soxhlet's 
Nahrzucker. The stools are constantly scrutinized and, if 
they continue normal, the percentage of additional carbo- 
hydrate is by gradual steps increased to 5,. tO' 6, or to 7 
per cent. This is necessary tO' maintain bodily heat and to 
provide for a reasonable gain in weight. 



TREATMENT. 271 

As soon as a gain is inaugurated, other conditions being 
normal, after omitting one or two^ feedings, an immediate 
return is made to some whoile-milk formula, the character 
of which depends upon the age and weight of the child. It 
is best to start with weak dilutions of skimmed milk, and 
then to proceed to weak dilutions of whole milk (say i 
part of milk and 3 parts of water) and to gradually increase 
the strength of the milk. Cane-sugar or some maltose 
preparation is still employed to provide carbohydrate, and 
the diluent of the milk should be some starchy preparation, 
preferably barley-water, wheat-flour water or, still better, 
arroiwroot-water. This provides an excellent means of 
attenuating the curd of cows' milk, rendering it digestible. 
The digestibility of the milk may be decidedly increased by 
pancreatization or by using flour ball and pancreatin, or 
Benger's Food. If there be a tendency toward looseness of 
the bowels the sugar should be markedly reduced or tem- 
porarily omitted. Meanwhile 5 tO' 10 grains of fullers' 
earth is administered internally in order tO' thicken the 
stools. 

Should there at any time occur a real relapse, the treat- 
ment just outlined must be repeated. The danger, however, 
is that after twO' or more attacks the strength of the pa- 
tient is so low that it is impossible for the infant to< support 
another "hunger period," as the tolerance for food of any 
kind may be so' depressed as to prevent the infant from 
receiving sufficient nourishment to sustain life, and dissolu- 
tion ensues. In other words, the food tolerance is far be- 
low the food' minimum (von Pirquet). 

Where marked intolerance for sugar does not exist, 
weak dilutions of Ramogen, somatose milk, and of con- 
densed milk form valuable adjuncts in the treatment of 



272 DIARRHEA. 

diarrhea. They are of especial use as go-betweens, as it 
were, during the period of starvation and the time when a 
return is again made to skimmed milk or toi whole-milk 
dilutions. Even in cases where sugar can be determined as 
the primary cause of the intestinal upset, these substances 
may be of use as tolerance for carbohydrate is. again grad- 
ually established. 

Treatment Other Than by Diet. — If the infant has lost 
much water this must be supplied by the drop-method per 
rectum, by mouth in definite amounts, by the dropi-method 
by mouth, or by hypodermodysis, according to the urgency 
of the indication (Chapter XIII). Plain tapn water may be 
employed, but normal saline solution is perhaps preferable. 
A solution containing i dram of sodium chlorid and i dram 
of sodium bicarbonate to the pint is the one which I com- 
monly employ. 

If the temperature be high, especially during the sum- 
mer months, frequent bathing is essential. It combats shock 
and soothes the infant's nervous system. The bath should 
be warm (ioo° F.) and gradually cooled (80° to 75° F.). 
The cold bath is abominable. An excellent method is that 
proposed by Henry Illoway, M.D., of New York, who 
employs the wet pack, consisting of a sheet wrung out of 
tap-water. The infant is enveloped in this and permitted 
to lie in it for hours. When it gets warm or when the 
infant's temperature starts to rise, the wet sheet is renewed 
and an ice-cap is kept to the head. The wet pack not only 
reduces temperature, but has an excellent effect upon the 
nervous symptoms, causing the infant in most cases to drop 
off into a refreshing slumber. The etiologic influence of 
external heat is decidedly mitigated and the pack often 
seems to assist in the actual reduction of the number of 
stools. 



TREATMENT. 273 

Colonic irrigation as a routine method of treatment is, 
in my judgment, of very little use and frequently does hann 
by increasing the amount of mucus, if it be too long con- 
tinued. As an initiatory remedy employed but once, it may 
render signal service in reducing temperature, lessening 
toxemia, and by ridding the bowel of a mass of offensive 
material. Likewise in cases of actually demonstrative sig- 
moidal and rectal ulceration occurring as the result of 
secondary infection, and in which blood is found in the 
stools, daily or bidaily flushing of the bowel with a warm 
2 per cent, solution of tannic acid is of much value. About 
2 quarts should be employed. 

Vomiting in the beginning of severe cases of intoxica- 
tion is a benign process with which no attempt should be 
made to interfere. Stomach washing is valuable late in 
the course of severe cases where the vomiting occurs as the 
result of tO'xemia. One or two washings may be sufficient. 
A solution containing i dram of bicarbonate of soda to the 
pint oif water is best. It should be used warm. A point in 
technique may be of considerable service. After the fluid 
returns clear, the tube is not withdrawn, but a feeding is 
poured into the funnel and allowed to enter the stomach. 
The tube is pinched and withdrawn by a swift movement 
between gags. A meal given in this manner is often re- 
tained when otherwise it would be vomited (Chapter VII). 

Medicinal. — My feeling is that drugs should play a very 
small part in the management of these cases. To secure 
rest of the nervous system and to conserve for the infant its 
energy, a hypodermic injection of from' ^/go to ^/loo grain 
of morphin sulphate is decidedly useful. Recognizing 
that the physician- is often forced to administer medicine 
against his better judgment, those remedies only should be 

18 



274 DIARRHEA. 

employed Avhich do the least harm. Calomel and intestinal 
antiseptics are practically useless and, for reasons already 
enunciated, should not be employed. Digestants like pan- 
creatin and taka-diastase or a drop of the tincture of nux 
^'omica are at times good and helpful. Bismuth I believe 
to be inert as to its effects upon this condition, with the 
possible exception of the subgallate which I have employed 
in large doses (gr. xx every three hours) in combination 
with 10 minims each of the tincture of kino, camphorated 
tincture of opium-, and listerine, with cinnamon- water as the 
vehicle. The mixture was discontinued as soon as hem- 
orrhage was controlled. Czerny employs the juice of 
dried or fresh blue berries. In older children he administers 
this with potatoes in the form of a soup. I have in two or 
three cases of severe bleeding employed, along with tannic 
acid irrigations, }i grain of emetin hydrochlorid, I think, 
with good effect. 

DIARRHEA IN CHILDREN WITH TEETH. 

The problem is not so difficult. The presence of teeth 
indicates that the intestinal tract is ready to care for food 
which, requires previous comminution. Therefore the 
source of the diarrhea, viz., milk, may be omitted from the 
diet at once. An initial dose of castor oil usually in these 
children does good and rarely any, or but little, harm. Not 
less than yi ounce should be administered. Recourse should 
be had to starches, preferably well-cooked rice (three 
hours), arowroot- jelly, wheat-flour gruel, farina, cream of 
wheat, mashed baked potato, stale bread, mutton-broth and 
soft-boiled Qgg. AA'hile on this diet, which may be con- 
tinued for weeks, improvement speedily occurs. The diges- 
tion may be materially assisted by the use of pancreatin and 



DIARRHEA IN CHILDREN WITH TEETH. 275 

of taka-diastase. Two- grains of each are adm>inistered 
every four hours. Recovery will in most instances ensue 
without the use of medicaments. Should these l>e found 
necessary some preparation containing tannic acid, as kino, 
geranium, catechu, or tannigen, will be found tO' 1)€. the most 
serviceable if used in combination with small doses of pare- 
goric. Fullers' earth (gr. x every four hours) will also 
thicken the stools. As soon as the latter become normal a 
return should be made tO' milk preparations — as eiweiss- 
milch, buttermilk-and-flour mixture without sugar, but 
sweetened with saccharin, or skimmed milk, V.-? diluted ^/g 
with arrow root- water, with the addition of ^/g ounce of 
Larosan and the whole sweetened with saccharin. Gradu- 
ally dilution of whole milk is made and the Larosan is 
omitted. Sugar is slowly added for a while. Flour ball 
and pancreatin may be employed, or Benger's Food. Any- 
way, plain whole milk should be cautiously reached and this 
should be boiled for some time after the attack. In using 
skimmed milk under all circumstances this should be em- 
ployed by skimming the best milk obtainable, at home. 



CHAPTER X. 
SPASMOPHILIA. 

Synonyms. — Spasmophilic diathesis, Tetany. 

Definition and Nature. — Under the term^ spasmophilia 
are correlated the evidences of nervous irritability in infants 
and young children which have been knov^n to the pro'- 
fession for a long time. These conditions are mainly 
laryngospasm, carpopedat spasm, tetany, and convulsions. 
Instead of regarding each as a separate and distinct disease 
with a special etiology and special therapeutics, under the 
term spasmophilia, they have been united as a single entity 
depending upon a basic cause or diathesis which is deter- 
mined by certain metabolic disturbances which, though not 
definitely proven, certainly exist, and which depend upon 
dietetic errors. Spasmophilia may, therefore, be character- 
ized as a state of abnormal nervous irritability. Most cases 
occur after the third month, although there are exceptions 
to this, some earlier instances being met especially in pre- 
mature infants. Rarely, if ever, are cases seen in the breast- 
fed, — a fact to which much significance must be attached. 
In the Waisenhaus und Kinderasyl in Berlin over 50 per 
cent, of the infants which are artificially fed show the evi- 
dences of this diathesis. The vast majority of these babies 
receive eiweissmilch. 

PATHOLOGIC ETIOLOGY. 

Before 1890 the spasmophilic diathesis was little under- 
stood. Escherich and Lows first noted the constant asso- 

(276) 



PATHOLOGIC ETIOLOGY. 277 

ciation of convulsions and laryngospasm with increased 
nerve irritability. 

About the same time Gai and Ganghofner noted the 
association of eclampsia, (convulsions) and irritability of 
the nerves, and concluded that the former occurred as a 
consequence of the latter. Thiemich and Mann were the 
first to study and to measure the electrical reactions of these 
cases, and to determine the normal number of milliamperes 
w^hich were sufficient to cause muscular contraction. It 
was discovered that the minimum amount of galvanic cur- 
rent necessary toi produce a contraction of a muscle in a 
normal infant, when the anode was opened, registered 5 
milliamperes. 

Number of Amperes Necessary to Produce Muscular Contraction 
IN A Normal Child. 

C C. C. 1 A. C. C. 2 A. O. C. 3 C. O. C.4 

Under 8 weeks 2.61 2.92 5.12 9.28 

About 8 weeks 1.41 2.44 3.63 8.22 

Number of Amperes Necessary to Produce Muscular Contraction 
IN Manifest, Latent and Passed Spasmophilia. 

C. C. C. A. C C A. O. C. C. O. C. 

Manifest 0.63 i.ii 0.55 1.94 

Latent 0.70 1.15 0.95 2.23 

Passed 1.83 1.72 2.34 7.904 

These figures are averages, but serve to indicate that in 
the presence of spasmophilia decidedly less current is re- 
quired to produce the muscular contractions. 

Finkelstein first named this state of nervous excitability 
spasmophilia. Inase; working with Escherich, noted the 

1 Cathode-closing contraction. 

2 Anode-closing contraction. 

3 Anode-opening contraction. 

4 Cathode-opening contraction. 



278 SPASMOPHILIA. 

presence of hemorrhages into the parathyroids in many new- 
born babies, and to the destruction of the parenchyma of 
these glands, occurring as the result of these hemorrhages, 
Escherich ascribed the cause of spasmophilia. Finkelstein 
objected on the ground that, if the causative hemorrhage 
occurred at birth, it was difficult to understand why, with 
but rare exceptions, the symptoms did not appear until three 
months later. He propoised that the cause was due tO' faulty 
metabolism by reason of which some substance, which he 
did not name, entered the blood. He inclined tO' the view, 
however, that the salts of the whey of cows' milk were the 
responsible factors, because it is well known that nearly all 
cases occur in the artificially reared, and he claimed further 
that the symptoms could actually be produced by whey 
feeding. This statement, however, requires confirmation. 

Stoeltzner (Halle), after feeding lime to children, de- 
cided that this caused the increased nervous response to the 
electric current, and concluded that with artificial feeding 
there is an increased accumulation of lime in the system, 
especially since there is at least five times as much lime in 
cows' milk as in human milk. This he claimed increased 
the nerve irritability. On the other hand. Quest found that 
in the brains of children, dead of tetany, there was a defi- 
ciency of lime-salts. His conclusions, therefore, exactly 
reversed those of Stoeltzner, and he found that dogs, fed 
upon a diet poor in lime, exhibited diminished resistance 
to the electric current. In confirmation of this, and also- 
linking together the theory of a disturbance of metabolism 
on account of impaired parathyroid function with that of 
lime starvation, MacCallomi found a deficiency of lime in 
dogs in whom the parathyroids had been extirpated. 

Up to the present time, therefore, it must be stated that 



PREDISPOSING CAUSES. 279 

the exact etiologic factor or factors have not been deter- 
mined, although it would appear that the truth lies some- 
where betzueen the theory of lime starvation and that of dis- 
turbed function of the parathyroids. The former occurs 
either as a consequence or as an association of the latter. 
Much credence must be given to the lime-starvation theory, 
because, recently, the best results have been obtained after 
treatment with calcium bromide. 

PREDISPOSING CAUSES. 

The fact that the same exciting factor does not induce 
spasmophilia in every child permits us to assume that 
heredity, as far at least as predisposition is concerned, plays 
a role oi no mean importance. The disease is not infre- 
quently seen in many children of the same parents. This in 
itself, however, offers nO' convincing proof that the same 
exciting etiologic influence may be responsible in each case. 
It has, nevertheless, been noted that parents whO' present 
neuropathies are likely to have spasmophilic children. 

The disease is commonly confined toi those infants who 
are artificially reared. Especially is this true where the 
feeding has been mismanaged, and where the food, in both 
quality and quantity, has been incorrect. As a consequence 
of this, the occurrence of frequent digestive disturbances 
has interfered with the proper progression of the infant's 
nutrition and development. Babies who are underfed, as 
well as those who are overfed, however, are pre-eminently 
predisposed to this condition, especially if the malnutrition is 
associated with chronic digestive disturbances. 

All exhausting diseases, prolonged infections especially, 
predispose to spasmophilia. It is also worthy of note that 
the acute infectious diseases, notably pneumonia, occur 



280 SPASMOPHILIA. 

with greater severity in spasmophilics. These cases present 
the highest temperature, the greatest degrees of toxemia, 
and consequently the highest mortaHty. Further, by means 
of spasmophiHa, we have an explanation as to^ why sO' many 
of the acute infections, again notably pneumonia, are in- 
augurated in many infants by convulsions instead of by the 
rigor of the adult. The toxin is sufficient tO' transform a 
latent spasmophilia into a manifest one. 

Acute digestwe disturbances, as well as chronic, may 
also induce manifest tetany, a term which will be presently 
described. Thus is explained the occurrence of convulsions 
in an infant following the ingestion of some indigestible 
substance. We formerly regarded this as a reflex or toxic 
phenomenon, but had no means of explaining the method 
of its production, or why one child escaped and the other 
did not. The reason is that the infant is spasmophilic, i.e., 
the electrical excitability of its nervous system is intensified, 
and the mechanical or toxic irritation, or both, are sufficient 
to cause this latent status to; become manifest. 

Season exerts some influence. Most cases are seen be- 
tween January and April. Many occur in the autumn, and 
least are met during summer. 

Sex does not appear tO' have any effect. 

The association of rickets and spasmophilia in the same 
individual can be frequently noted. What interdependence 
exists between these two conditions has not been clearly 
established, although their frequent coexistence must be 
more than coincidental. It is probably true that each de- 
pends upon the same disturbance of metabolism that is pro- 
duced by improper feeding. Both are undoubtedly benefited 
by codliver oil and phosphorus. 



SYMPTOMS. 281 

SYMPTOMS. 
These may be classified under two groups: — 

A. Symptoms of latent spasmophilia, or tetany. 

B, Symptoms of manifest spasmophilia, or tetany. 
Both of these conditions must be carefully studied in 

order to exercise control over the diathesis, for at any time 
a latent spasmophilia may be transformed intO' the manifest 
type with fatal results. Each has, however, a distinct 
symptomatology, and each a distinct therapeusis. The 
treatment of manifest tetany must be prompt, while that of 
the latent, while just as important, need not be so hasty. 

A. Latent Spasmophilia, or Tetany. — This is character- 
ized by 

1. Certain reflex phenomena. 

2. Abnormal electrical reactions. 

I. Reflex Phenomena. — These are very important in 
establishing the presence of the diathesis. They must be 
divided intoi nervous reflex phenomena and muscular reflex 
phenomena. Under the nervous reflex phenomena we have 
(fl) facial phenomenon, or Chvostek's sign; {h) Trous- 
seau's sign. Under the muscular phenomena are included 
{a) the peroneus reflex and {h) the lip sign of Thiemich. 

B. Manifest Spasmophilia, or Tetany. — This includes 

1. Laryngospasmus. 

2. Carpopedal spasm. 

3. Eclampsia. 

4. Hard edema of hands and feet. 

There are other symptoms of more or less importance 
which will be described in their order. Before detailing 
the features of both latent and of manifest tetany, the fol- 
lowing is therefore presented as a summary of the impor- 



282 



SPASMOPHILIA. 



tant features, in order that they may be crystalhzed in the 
student's mind : — 



r A. Latent 



Spasmo- 
philia, 
or 

Tetany 







I. Facial 




phenomonon, 




' I. Nervous - 


or 
Chvostek's 
sign. 
2. Trousseau's 


I. Reflex 
phenomena' 




sign. 




2. Muscular-' 


1. Peroneus 
reflex. 

2. Lip phe- 
nomonon of 
Thiemich. 


2. Abnormal 


electrical reactions. 



B. Manifest 



p I. Laryngospasmus. 

2. Carpopedal spasm. 

3. Eclampsia. 

(^ 4. Hard edema of hands and feet. 



Facial Phenomenon, or Chvostek's Sign. — Search should 
be made for this in every child after 2 months, as it is a 
constant feature of both manifest and of latent tetany. It 
may be positive on one side of the face only. Hence both 
sides should always be tested. It is elicited by tapping 
lig-htly with a percussion' hammer (plexor — Fig. 46) on 
the face just below the zygomatic process of the superior 
maxilla. This is followed by a contraction (sometimes 
very slight and evanescent, and therefore the most careful 
scrutiny must be exercised) of the muscles of the face 
and of the upper eyelids, and of the wing of the nose. 
The facial contraction may not occur, and the phenomenon 
may be confined to the upper eyelid alone. Therefore, this 
portion of the face should be most carefully visualized. 



SYMPTOMS. 283 

The contraction in any event is faint or intense, depending 
upon the degree of nervous excitabiHty. The features must 
be in repose when this test is made, and, therefore, it can- 
not be successful if the baby is crying. While this sign is 
present in practically every case of spasmophilia, it is not 
pathognomonic of this affection. At least the author has 
been able tO' demonstrate it in cases of tuberculous menin- 
gitis. It may be that these infants were spasmophilics as 
well. However, positive reliance should not be placed upon 
this sign alone, and every case in which the condition is 
suspected should be studied for the electrical reactions as 
well if this be at all possible. 




Fig. 46. — Percussion hammer. 

Trousseau's phenomenon occurs as the result of pres- 
sure exerted upon the main nerve and blood-vessel of a long 
extremity, usually the arm. The pressure is applied either 
by the thumb and forefinger of the examiner encircling the 
upper arm, or by tying a band, rubber or othenvise, about 
the part sufficiently firm to cut off the circulation at the 
wrist. The reaction, if positive, may not be seen at once. 
Shortly, however, the muscles of the hand (if the band has 
been placed about the arm) or foot (if the band has been 
placed about the thigh) and of the lower arm or leg com- 
mence to contract and to cause the extremity to assume the 
characteristic attitude of carpopedal spasm. If this test is 
positive it indicates spasmophilia without question. Unfor- 
tunately it is not always present and is, therefore, not so 



284 SPASMOPHILIA. 

reliable as Chvostek's sign. Further, it causes pain, and 
parents often object to its use, as it appears cruel and un- 
necessarily harsh to them. In nO' case should it be employed 
until the close of the examination. 

The peroneus phenomenon is obtained by tapping the 
peronei muscles on the outer aspect of the leg with the per- 
cussion hammer. If positive, this causes the outer aspect 
of the foot toi be drawn up and the toes to be raised and at 
the same time to be slightly separated. While this reflex 
is more reliable than Trousseau's, it is not always present, 
either. On the other hand, stress must again be laid upon 
the fact that there is never a case of either latent or of 
manifest tetany in which Chvostek's phenomenon is absent. 

Lip Phenomenon. — This was first described by Thre- 
mich, and is oibtained by tapping the orbicularis oris. This 
causes the muscle to contract with the result that the lips 
are closed and slightly protruded and appear as in the act of 
kissing. 

Abnormal Electrical Reactions. — Muscular contractions 
normally occur when the galvanic current is applied to the 
muscles of the infant. These contractions are designated 
as follows: — 

Cathode-closing contraction (C. C. C), i.e., when the 
cathode is applied over the muscle and the anode is placed 
on the abdomen or upon the back, a muscular contraction 
occurs when the current is sufficiently strong for the in- 
dividual muscle, at that time, when the circuit is closed. 

Cathode-opening contraction (C 0. C), the same con- 
ditions obtained as just described, and the muscle contracts 
when the circuit is opened. 

Anode-closing contraction {A. C. C), the electrodes are 
reversed, i.e., the anode is placed upon the muscle and the 



SYMPTOMS. 285 

cathode upon the back or abdomen. A contraction occurs 
when the circuit is closed. 

Anode-opening contraction {A. 0. C), the same con- 
ditions obtain as in the preceding except that the circuit is 
opened. 

It is seen therefore that when making an anode exami- 
nation the anode is placed upon the muscle and the cathode 
upon the abdomen or back, and when making a cathode 
examination the cathode is placed upon the muscle ex- 
amined and the anode upon the back or abdomen. In 
either instance the electrode which is placed upon the 
muscle is called the ''differ en f electrode and that placed 
upon the abdomen or back is called the ''indifferent" elec- 
trode. The former must always be three square centi- 
meters in area, and is usually placed upon the median nerv^e 
just above the bend of the elbow on the anterior surface of 
the arm. This nerve supplies the thumb, the index-finger, 
the middle-finger, and half of the ring-finger, and as the 
current is applied the muscular contractions in these digits 
are noted, especially that of the index-finger. The latter 
must be not less than fifty square centimeters. The so- 
called normal electrical reaction, indicating the amount of 
galvanic current necessary to produce a muscular contrac- 
tion in a nonnal infant, is tabulated on page 277. Refer- 
ence to the same table zmll demonstrate that, under abnor- 
mal conditions, less current is required to bring about a 
contraction. These are the so-called abnormal electrical 
reactions. They are pathognomonic of latent tetany, and 
occur, of course, as well in manifest tetany. 

The following will sen^e as a practical example of what 
occurs in a case of spasmophilia. The electrodes are so 
placed, and the switch on the electrical apparatus so ad- 



286 SPASMOPHILIA. 

justed, that the cathode becomes the ''different" electrode. 
The absolute size of the milliamperage required to produce 
a cathodal-opening contraction is the indicator of the scAxr- 
it}' of the spasmophilia. Look for the smallest amount of 
milliamperage which will produce a C. O. C. Suppose i 
milliampere of current is flowing through the electrode as 
shown on the milliamperemeter and no contraction occurs. 
Slowly increase the current. Suppose at 3 milliampere- 
meters a C. C. C. takes place. With this amount of current 
the C. O. C. is still negative. Increase the current to 4 
milliamperemeters. A distinct C. O. C. is seen. Decrease 
the current very slowly sO' that the smallest amount of cur- 
rent which will produce a C. O, C. can be estimated. Let 
us assume this to be 3.5 milliamperemeters, and it may be 
further assumed that at 3.3 milliamperemeters no C. O. C. 
occurs, but only the C. C. C. is present. Result: 3.5 milli- 
amperemeters constitute the smallest amount of current that 
will produce a C. O. C. In normal children the necessary 
amount of current to produce a C. O. C. is 5 milliampere- 
meters, and anything less than this indicates spasmophilia. 

By means of these electrical reactions we can best deter- 
mine the presence of both latent and of manifest tetany. 
They are present in every case, although, when other symp- 
toms are in evidence, it is unnecessary to search for them 
in order to reach a correct clinical diagnosis. However, 
the prognosis and the effect of treatment can be accurately 
gauged in this manner and, therefore, whenever possible the 
reactions should be taken at frequent intervals — daily at 
first, then triweekly, biweekly, and so on. Cards may be 
kept on file, graphically illustrating the diagnosis and prog- 
nosis of an individual case. If accurate electrical studies 
are impossible, the prognosis and the effect of treatment 



/ 
SYMPTOMS. 287 

may be studied as well, although less minutely, by fre- 
quently testing for the Chvostek sign and noting its gradual 
disappearance. 

Laryngospasmns. — This is a convulsive state of the 
glottis in which a crowing sound occurs during inspiration. 
An attack is frequently inaugurated during crying or from 
fright. It is commonly seen in older children following 
pique, temper, or punishment, and who have the underlying 
diathesis. On the other hand, an infant may be awakened 
from sleep by an attack. The crowing sound is characteris- 
tic. It must be distinguished from a similar sound which 
occurs in infants but a few weeks of age. This is known 
as stridor inspiratorius congenita, and is differentiated by 
the age of the infant, the absence of other symptoms and 
of the electrical reactions, and by the effect of antispasmo- 
philic treatment upon true laryngospasmns. In the latter, 
following the spasm of the glottis, there is a state of apnea 
which is associated with tonic spasm of all the respiratory 
muscles, those of the diaphragm and of the bronchi as well. 
The child becomes pale and finally blue. As soon as the 
spasm relaxes, the crowing sound occurs as the air enters 
the lungs. The attack seldom lasts longer than thirty or 
sixty seconds. The occurrence of the crow indicates the 
end of an attack. One attack may immediately follow 
another, and the number which may occur in twenty-four 
hours is indefinite, as many as fifty per diem having been 
noted. Coma and convulsions may be associated phe- 
nomena, ending in death. If the crow does not appear the 
outcome is commonly fatal. Escherich ascribes the death 
to cardiac failure, although this point has not been accu- 
rately established, as the respiratory center may as well be 
involved in the paralysis. Mothers frequently bring their 



288 SPASMOPHILIA. 

babies for treatment because, as they say, "the baby holds 
its breath when it cries." As a matter of fact, no air has 
entered the lungs. 

Carpopedal Spasm. — Tonic contractions of the muscles 
of the upper and of the lower extremities characterize this 
symptomi. The contractions last for days and weeks, 
although temporarily they may partially or completely 
relax. They are so intense that any attempt tot straighten 
the extremities causes crying on account of the pain thereby 
induced. The forearms are flexed upon the arms and the 
latter are adducted and lie close tO' the chest-wall. The 
hands are sharply flexed upon the forearms and the fingers 
are flexed as far as the metacarpophalangeal articulation, 
from which point the phalanges are extended. The thumb 
is adducted and its tip frequently touches the tip of the little 
finger. 

Under the older classification this condition of tonic 
spasm of the upper and of the lower extremities was 
described as tetany, a distinct disease, and not as a manifest 
symptom of the spasmophilic diathesis, and the appearance 
of the hand was described as that of a driver reining in his 
horse. On the other hand, the Germans describe the appear- 
ance as "Geburtshelfer's hand," or the attitude asstimed by 
an obstetrician in delivering a child. The hand itself is 
likened to a little paw of a kitten (Pfoetchanstellung). The 
spasm may be confined to the hands and feet, not involving 
the extremities. 

The thighs are commonly flexed upon the belly and the 
legs may be upon the thighs. The feet are sharply extended. 
They may be in the position of equinovarus. The phalanges 
of the toes are flexed up to the second and third rows, which 
are extended. The back of the foot becomes very promi- 



SYMPTOMS. 289 

nent, and gives the appearance of edema on account of its 
increased convexity. The under surface of the foot is 
arched. 

Tonic contractions may involve the muscles of the neck 
and cause the infant to assume the position of opisthotonos. 
The body may be bent forward, on the other hand — 
emprosthotonos. The muscles of the forehead are com- 
monly involved and the latter may therefore be wrinkled. 
The mouth may be puckered (Karpfenmund, or carp's 
mouth). 

Eclampsia, or convulsions, occurs in infants as a com- 
mon clinical experience. This must never be regarded as a 
distinct disease, but merely as a symptom of an underlying 
cause or diathesis. Where organic and inflammatory dis- 
ease of the nervous system, kidney lesions, and epilepsy can 
be excluded, careful investigation will frequently reveal the 
presence of the spasmophilic diathesis. As will be detailed 
later, this fact is of immense importance in the treatment 
of convulsions, especially in its relation to their prevention, 
and sheds much new light upon this frequently fatal con- 
dition. The convulsions are clonic and nearly all the cases 
which ordinarily occur in childhood must be included under 
this caption. 

Hard Edema. — A peculiar swelling of the hands and 
feet is a frequent, although not a constant, accompaniment 
of tetany. It is not a true edema, as pitting does not occur. 
It is probably a vasomotor disturbance of the skin. The 
hyperextension of the feet already referred to assists in 
causing the cushion-like appearance of the dorsum of the 
feet. 

Other Symptoms. — Where very severe generalized in- 
volvement obtains, retention of urine and obstinate consti- 

19 



290 SPASMOPHILIA. 

pation may ensue from intense spasm^ of the sphincters. In 
the latter instance the abdomen may become much dis- 
tended. As the spasm relaxes there occurs a discharge of 
feces and of gas, and the distention may thus suddenly dis- 
appear. Lingual and esophageal spasms have been noted. 

The pupils are contracted and do not respond to light. 
Nystagmus and strabismus may alsoi occur. Spasm of the 
bronchi may appear independently of all other features of 
the disease. 

The clinical picture may assume, therefore, the ap- 
pearance of pneumonia (Lederer). The absence of physical 
signs, temperature, leucocytosis, and the presence of the 
electrical reactions of spasmophilia or of the facial or 
other reflex phenomena, will permit of a correct differ- 
entiation. 

In manifest tetany, we may encounter vasomotor dis- 
turbances involving the skin, and resulting in urticaria, ery- 
thema, profuse sweating, and intense, though evanescent, 
edema locally situated or of the entire body. The latter, 
upon superiicial examination, may be mistaken as due to 
nephritis. Digestive disturbances occur both in cases of 
latent and of manifest spasmophilia. 

Irregular Forms.— Ihe first symptoms may appear be- 
fore the fourth month. The order of the appearance of the 
symptoms may be reversed, i.e., the features of manifest 
tetany, laryngo spasmus, and of the electrical reactions or 
the other phenomena,, which indicate the spasmophilic basis, 
may appear before the characteristic features of the di- 
athesis are in evidence. Sooner or later, however, these 
appear, as does the facial phenomenon of Chvostek. The 
diagnosis is sometimes, therefore, made' with difliculty, and 
must depend upon the results of antispasmophilic therapy. 



DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 291 

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 

The diagnosis depends upon the typical symptoms just 
detailed. Of greatest importance are the Chvostek sign 
and positive electrical reactions. The detection of latent 
spasmophilia depends largely upon a study of these two 
features and of the reflex phenomena. 

The discovery of the latent diathesis really constitutes 
the crux of the dagnosis, for it is distinctive of this condi- 
tion alone and serves to properly catalogue the symptoms 
of manifest tetany, which so closely resemble other diseases. 
These need but be mentioned, for in all a study of the re- 
flexes and of the electrical reactions will render the diag- 
nosis clear. They are epilepsy, cerebrospinal meningitis, 
tetanus, and any other disease in which irritative or con- 
vulsive symptoms are prominent features. Reference has 
been made to the occurrence of a positive Chvostek in men- 
ingitis. However, this need cause no confusion, as other 
symptoms and the information provided by lumbar punc- 
ture will permit of a correct conclusion. It is especially 
difficult, in some cases, where a knowledge of the character- 
istic symptoms of spasmophilia is lacking, to say that a 
particular child has or has not epilepsy. This is particularly 
true of those brief convulsive attacks associated with 
momentary loss of consciousness, and which are commonly 
precipitated by anger, fright, or stubbornness, and which 
so closely resemble petit mal. Stridor inspiratorius has 
already been considered. Laryngospasmus must not be 
confused with the convulsive stage of pertussis, laryngeal 
diphtheria, and retropharyngeal abscess. Many cases of 
thymic death, so called, where no enlargement of the thymus 
is demonstrable, are undoubtedly due tO' laryngospasmus. 



292 SPASMOPHILIA. 

PROGNOSIS. 

Where recognized and promptly treated, the outlook for 
permanent and perfect recovery from this disease is ex- 
cellent. This is not only true of the manifest variety but, 
with equal emphasis, of latent spasmophilia. Death may 
unexpectedly ensue, in an otherwise apparently healthy 
child, from laryngospasmus or from eclampsia. Even in 
mild cases, which are untreated, complete effacement of all 
evidences of the diathesis may occur. On the other hand, 
in these, and also in those energetically treated, remains of 
the condition may persist into adult life. This is particu- 
larly true of Chvostek's sign. It must not be forgotten 
that, under any exciting factor, the latent spasmophilia 
which has for years persisted undetected, may be speedily 
transformed into any one of the dangerous expressions of 
the manifest type, and with a fatal outcome. For this 
reason each child should routinely be studied at least for the 
facial phenomena, if search for the electrical reactions be 
impossible. 

TREATMENT. 
Prophylaxis. — As the disease is not found in breast-fed 
infants it logically follows that every effort should be made 
to consen-e the maternal milk. If this fails, properly 
directed artificial feeding should be instituted and great care 
exercised to prevent overfeeding and consequent digestive 
disturbances. 

. Active Treatment. — This is directed toward (a) treat- 
ment of the diathesis or of latent spasmophilia and (b) 
treatment of the symptoms or of manifest spasmophilia. 

(a) Treatment of Diathesis. — This is accomplished by 
proper diet and carefully directed medicinal treatment. 



TREATMENT. 293 

Most cases will recover if placed iqxjii jjreast milk. 
Where dependence must be had upon artificial feeding it is 
necessar}^ to distinguish between those babies which are 
being overfed and those which are underfed. 

Overfed Babies. — A hunger period should be instituted 
for from six to tw^elve hours. The metabolic processes are 
thereby rested and a readjustment of the infant's organism 
is permitted. During this time weak tea, sweetened with 
saccharin (gr. j to i quart), alone may be given. Following 
this a 5 per cent, solution of some form, of cooked flour — 
wheat, barley, rice, oatmeal, or arrowroot — is administered 
for eight days. Small quantities of w4iole milk are now 
judiciously added, commencing with about 50 grams per 
diemi This is mixed with the flour solution. An initial 
loss O'f weight usually occurs and is of no consequence if not 
too long continued. Therefore the daily amount of milk is 
cautiously increased, care being exercised not to proVoke an 
acute digestive disturbance, as this may be responsible for 
the appearance of an attack of acutely fatal manifest tetany, 
— for instance, laryngospasmus. 

Underfed Babies. — A hunger period is here decidedly 
contraindicated. In an underfed infant an acute alimentary 
disturbance must be overcome as quickly as possible. 
Where gray, constipated stools are in evidence (Bilanzstoe- 
rung), carbohydrate is lacking in the diet, and its addition 
favorably influences the progress of the case. For this 
reason, these cases speedily improve on malt-soup or butter- 
milk to wdiich sugar and flour have been added (Chapter III, 
page 123). If the stools and weight curve indicate chronic 
dyspepsia, sugar is omitted. Each case must be individual- 
ized. Intestinal intoxication calls for eiweissmilch and a 



294 SPASMOPHILIA. 

decomposition must be treated with suitable milk mixtures 
or breast milk. 

Medicinal Treatment. — The best remedy, acting prac- 
tically as a specific, is codliver oil combined with phos- 
phorus : — 

I^ Phosphorus i centigram. 

Codliver oil lOO grams. 

M. Sig. : f5j administered over twentj-four hours and in- 
creased to fSiij. 

This is best administered one-half hour after meals, 
If the stools become dyspeptic the oil must be temporarily 
withheld. The good effect of this treatment is usually 
manifest after the eighth day. Cure is often effected within 
three to four weeks, although continuous administration of 
the oil and phosphorus must be practised for from three to 
four months. This is true also of cases placed upon the 
breast, for the latter alone may not be sufficient to produce 
a disappearance of the manifestations of latent spasmophilia. 

In some very mild cases which are receiving cows' milk, 
it is sufficient simply, in conjunction with the oil and phos- 
phorus treatment, to reduce the daily amount of cows' milk 
which the infant is receiving. Thus, if this be 800 grams 
per diem, it may be reduced to 400 grams and the calories 
thus lost are supplied by flour-gruels. 

{h) Treatment of Manifest S p asm op hi Ha. ^-The most 
important symptoms which require active treatment are: 
(a) convulsions, (b) laryngospasmus. 

Convidsions. — Chloroform is not recommended by the 
German authorities, although in America it is almost 
routinely employed. When judiciously handled it produces 
beneficent results and its administration mav be continued 



TREATMENT. 295 

cautiously over a prolonged period of time. Of late the best 
Continental physicians employ calcium hromid: — 

I^ Calcium bromid lo grams. 

Aquae destill 200 grams. 

M. Sig. : From 2 to 3 grams {Yz io Y^ dram) to be administered 
daily. 

If the soporific effect be too persistent, less may be employed 
or the drug may be temporarily suspended. 

Though not as valuable, chloral hydrate may l^e substi- 
tuted for calciumi bromid if this chemical is not to be had : — 

Chloral hydrate 2 grams. 

Aquae destill 100 grams. 

Ten grams of the solution are equivalent to 0.2 gram of 
chloral hydrate. This is administered by mouth every two 
hours or 3^ gram of chloral hydrate may be employed per 
rectum as follows: — 

Chloral hydrate i gram. 

Gum-arabic 5 grams. 

Aquae destill q. s. ad 50 grams. 

This represents two doses. Personally I favor, and have 
obtained prompt and permanent effects from, the adminis- 
tration of morphin: — 

Morphinae sulph i centigram. 

Aquae destill 50 grams. 

One fiuidram of this solution equals 3 milligrams, which is 
the dose. The best eft'ects, however, are probably secured by 
administering the drug hypodermically in the dose of from 
V200 to Vso grain. 

Gastric lavage should be practised if the histoiy indi- 
cates a recent dietary indiscretion, especially if sufficient 
time has not elapsed to permit the food to have passed from 



296 SPASMOPHILIA. 

the stomach. While the tube is still in place, if the child 
be unconscious, a dose of castor oil may be administered in 
this manner. On the other hand, a dose of bromid and 
chloral may also be given in this way. Colonic irrigation 
should be practised at least once. In other words, by 
mechanical and medicinal means it should be positively 
ascertained that the gastrointestinal tract has been thor- 
oughly cleansed. 

The treatment of an attack of laryngospasmus differs 
in no important essential from that of convulsions. 



CHAPTER XI. 

EXUDATIVE DIATHESIS. 

Definition and Nature. — To the German pediatrists, 
especially to Czerny (Berlin), belongs the credit of crystal- 
lizing, under this tenn, which clearly represents a disturb- 
ance of metabolism, an ensemble of familiar clinical phe- 
nomena occurring with great frequency in infants and 
children. The condition i^ characterized by the frequent 
incidence of fibrinous or exudative inflammatory processes 
zvhich attack principally the skin and mucous membranes. 
These processes appear as eczema, and as catarrhal involve- 
ment of the respiratory and gastrointestinal tracts, respect- 
ively. Many of these patients suffer from nervous dis- 
turbances as well. The lymphoid tissues may exhibit 
chronic enlargement. Decided interference with the bodily 
nutrition may be noted in some cases. 

ETIOLOGY. 

Predisposing Factors. — Although not manifesting itself 
immediately after birth, in all cases the condition is, in all 
likelihood, congenital. The exudative diathesis itself is a 
latent process. It is, as it were, a foundation upon which in- 
fection is easily implanted and rapidly develops. Thus, while 
the various evidences of inflammatory disease of the skin and 
mucosse constitute an essential portion of the clinical picture 
of the condition, they in themselves are not entirely due to 
the diathesis. Without infection brought to the parts by 
carelessness, accident, or filth, they could not occur. It is 
maintained, however, that without the presence of the 

(297) 



298 EXUDATIVE DIATHESIS. 

underlying diathesis, the infection would not develop. 
Thus, a reciprocal relation existing betzveen the diathesis 
and the infection brings the manifestations of the disease 
into existence. To further elucidate this point it may be 
stated that, according- to the German idea, infections of the 
human body occur in two- ways, viz., (a) enteral infection 
and {b) parenteral infection. The former means the en- 
trance of the infective agent through the intestines and is 
represented by typhoid fever, amebic dysentery, etc. The 
latter represents the entrance of the infection through 
avenues other than the intestinal tract; for instance, 
through the skin, as represented by eczema and erysipelas, 
and through the respiratory tract, as represented by 
laryngitis, bronchitis, and pneumonia. It is largely through 
these parenteral infections that the exudative diathesis 
becomes manifest. In other words, it is the predisposing 
factor. Some parenteral infections may even cause other 
manifestations of the diathesis, already present, tO' improve, 
while others intensify the symptoms. Of the first instance 
we have an example in the beneficent effect of an attack of 
measles upon eczema, and, of the second, it is well known 
that vaccinia and varicella will accentuate the symptoms of 
this disease. Therefore, unless the circumstances be un- 
usually urgent, an infant with eczema . should not be vac- 
cinated. It may be surmised, correctly, that there exists a 
resemblance between the clinical behavior of the exudative 
diathesis and that of spasmophilia. The latter, as we have 
seen, may be latent and becomes manifest only as the result 
O'f some exciting factor. 

The association of the exudative diathesis with spas- 
mophilia occurs with some frequency in the same patient. 
The relationship is not clear. The event is probably a co- 



ETIOLOGY. 299 

incidence, although the underlying factor in each instance 
is metabolic. 

Heredity undoubtedly plays a role of importance. 
Many children of the same parents present the symptoms 
of this diathesis. The parents themselves, more or less 
constantly, present evidences of pen^erted metabolic proc- 
esses. They are frequent victims of neurasthenia or of 
some neurotic manifestation, or suffer from lithemia, the 
so-called uric acid diathesis, rheumatism, diabetes, asthma, 
acidosis, indicanuria, or chronic skin affections. Environ- 
mental influences, however, may explain these results as 
well as heredity, as the disturbances, evident in the parents, 
may be due to dietetic and other determining factors which 
are permitted to operate constantly in the case of the 
offspring. 

The disease is not confined to those artificially reared, 
the evidences of eczema, especially, occurring, with much 
frequency, in the breast-fed. 

Unhygienic surroundings, as already intimated, consti- 
tute a predisposing factor of no mean importance. There- 
fore poverty, ignorance, overcrowding, and filth in every 
form must be considered. For this reason, too, the disease 
is more common in the city than in the country. 

Exciting Factor. — The exact cause is not known. Be- 
tween pediatrists and dermatologists there exists a differ- 
ence of opinion as to whether the skin manifestations are 
constitutional or local. The latter view is held by the der- 
matologists, who proclaim the futility of any but local 
treatment. The proper solution will, no doubt, determine 
that both local and constitutional causes are operative. 
There undoubtedly exists a reciprocal relation between the 
underlying diathesis and infection. Upon what does the 



300 EXUDATIVE DIATHESIS. 

diathesis depend ? As yet this has not been clearly defined. 
Czerny regards a disturbance in the fat metabolism as the 
underlying factor, but is unable to exactly describe the 
nature of this disturbance. On the other hand, Finkelstein 
inclines toward the view that the error lies with the water 
and with the salts. This finds some confirmation in the 
fact that certain breast-fed babies, who are gaining but 
slowly and who^ have eczema intertriginosum., are benefited 
by feeding toi themi the finely comminuted, coagulated pro- 
tein of cows' milk, with salt, in addition to giving them the 
breast. 

In this instance! the fat will not have been removed 
from' the diet. Finkelstein also suggests, as a possible cause, 
a disturbance in the nitrogen metabolism, in which too little 
nitrogen is absorbed. In any event it may be stated that 
somewhere in a perverted metabolism lies the cause and 
somewhere in diet lies the cure, because all cases are 
decidedly benefited by changes in the food and in the ex- 
ternal surroundings. 

Because of the enlargement of the lymphatic glands, 
not infrequently met, the relationship existing between this 
condition and the status lymphaticus has been considered, 
but the connection is not clear. 

SYMPTOMS. 

In order to attempt some form, of classification these 
will be discussed under (a) body weight, (b) skin manifes- 
tations, (c) respiratory phenomena, and {d) digestive 
symptoms. It is important to emphasize that both treated 
and untreated cases vary in their severity throughout the 
course of the attack, and apparently without the influence 
of external agencies. One set of symptoms will often 



SYMPTOMS. 301- 

ameliorate while another set, hitherto quiescent, will become 
intensified. The occurrence, therefore, of substitution 
phenomena is a part of the natural clinical picture of the 
disease. Thus, the skin symptoms may entirely disappear, 
to be followed by an attack of asthma or digestive disturb- 
ance, and these in their turn will be succeeded by an attack 
of eczema. 

Body Weight. — Two types of patients are affected : 
Underfed babies and overfed babies. It is important to dis- 
tinguish these two types, as experience has shown that, 
originating from this premise, two different lines of die- 
tetic management are necessary to secure good results. 
Reference will again be made tO' this classification. In 
general it may be stated that the underfed baby is thin, 
puny, and ''transparent," is stationary in weight, and likely 
to suffer from digestive disturbance and diarrhea. It 
often suffers from eczema seborrhoeicum universale, with 
intertrigo. 

The overfed infant appears fat and robust. These 
babies are, however, commonly anemic, have poor resist- 
ance, and exhibit the wet forms of eczema, especially of the 
face and head. They also have more or less digestive dis- 
turbance and may be constipated. 

Skin. — The dermal phenomena may be classified as 
neuropathies, eczemas, pruriginous inflammations, and 
strophulus. 

The first are seen as increased' vasomotor irritability and 
exhibit themselves, not uncommonly, as alternate flushing 
and paling of the surface, without apparent cause. This 
gives rise, at times, to the diagnosis of anemia (pseudo- 
anemia), an examination of the blood showing its hemo- 
globin content to be normal. Fugitive erythemas, itching, 



302 EXUDATIVE DIATHESIS. 

exanthemas, pruritus, urticaria, and dermoigraphia consti- 
tute the more common remaining skin neuropathies. 

The eczemas are usually found during the first year. 
Frequently they develop during the first weeks and even 
days O'f life. They rarely last beyond the end of the 
second year. Two^ principal types, of which there are sev- 
eral variations, exist: Eczema sehorrhoische imiversale, 
or universal seborrheic eczema, and eczema of the face and 
head. The latter may occur with the universal type. 

Eczema Sehorrhoische Universale. — This develops as a 
consequence of increased epidermal desquamation, and ex- 
hibits white or yellow scales which are more or less filled 
with inspissated sebaceous matter. It may appeaf upon the 
head and forehead and about the temples and eyebrows, or 
it may become diffuse and cover the entire body with 
scaling plaques. The oiily nature is best noted upon the 
scalp on account of the abundance of oil-glands in this 
situation. On the body cracks or fissures occur, and from 
these exude serum and blood which dry and form crusts. 
The covering of the scalp may be a complete mask in which 
the hair is matted in an untangleable mass (gneisz). 

A form, in which the scalp is simply covered with more 
or less oily scales, but in which the underlying skin is not 
inflamed, also' occurs. Removal of the crust reveals only a 
pale surface and there is no bleeding. This is known as 
seborrhea capitis. Itching is slight. On the other hand, 
should the skin beneath be red and angry, and itching be 
intense, then true seborrheic eczema is present. This is a 
dry type of eczema, and rarely is severe. 

Intertrigo, or eczema intertriginosum, in nearly all cases 
follows or accompanies eczema seborrhoeicum. It is the 
same process except that it is found in the folds of the skin. 



SYMPTOMS. 303- 

particularly at the joints, in the front part of the neck, and 
in the groins and behind the ears. The last is an especially 
common situation. In the groin it must not be confounded 
with simple maceration and slight irritation of the skin re- 
sulting from acid stools and urine and carelessness. This 
type is moist, while eczema intertriginosumi is frequently 
dry and the skin is always infiltrated or thickened and 
readily cracks. It may be mild or severe. These infants 
are often weak and under weight, and have mild, dyspeptic 
stools. 

Closely resembling this type of eczema is erythrodermia 
desqiiamativa, or Leiner's disease (Vienna). Finkelstein 
and Moro regard them as identical. Rarely eczema inter- 
triginO'Sum becomes infected with the diphtheria bacillus, 
when it assumes the clinical features of this disease. 

Eczema of Face and Head. — This type occurs most 
commonly after the fourth month. Careful observation 
will detect its presence almost at its inception. All infants 
with 'Ved cheeks" shoruld be objects of suspicion. Nor- 
fnally the cheeks of infants are not red. They possess the 
healthy skin color. This is true also' out-of-doors. In this 
type of eczema there is seen a more or less circumscribed 
area of redness on one or both cheeks. At first glance, and 
always to the untrained. eye, it may appear as the blush of 
health. 

The skin, however, will be observed to be somewhat 
inelastic, at times shiny, and to be covered with very fine 
scales. It itches but slightly, as a rule. The process may 
be stayed in its further development. Later papules may 
appear and itching may become so intense that the infant 
unmercifully tears its own flesh, causing it to bleed. Crusts 
are formed and infection is not uncommon. ^lany of these 



304 EXUDATIVE DIATHESIS. 

babies are transformed into pitiful sights, and suffer in- 
tensely from the scratching and tearing and crust formation. 
If their hands are tied they bury their heads into the pillow 
or rub them against any object in their frenzy to secure 
relief. Removal of the crusts (milk crusts, or crustalactea) 
is followed by bleeding. The skin of the rest of the body 
may appear quite normal. 

Sometimes, instead of papules, vesicles appear (eczema 
vesiculosum) or their place may be taken by pustules 
(eczema vacciniformis). This differs from, eczema vac- 
cinatum, which is due to, and occurs around the area of, 
vaccination. 

Phlyctenular conjunctivitis and keratitis impetiginosum 
are regarded by Czemy as eczema of the cornea. They 
occur in weak, anemic, underfed infants, and place a grave 
prognosis upon the final outcome of the disease. Heubner 
and Finkelstein deny the relationship of this condition to the 
exudative diathesis. 

Pruriginous Inflammations. — The staphylococci which 
normally inhabit the skin may become pathogenic, as a re- 
sult of the lowered resistance due to the exudative diathesis, 
and thus be responsible for pruriginous inflammatory proc- 
esses. The most common expressions of this condition are 
furunculosis, ecthyma, and infected pemphigus. 

Strophulus. — This appears in older infants and children 
as a rule. It resembles urticaria in the sense that the lesions 
ma}^ appear as wheals. They are not as evanescent, how- 
ever. More often they occur as simple small papules on the 
apices of which appear minute, deep-seated vesicles. The 
lesions occur anywhere on the body, most often, however, 
on the extremities and buttocks. They itch intensely and 
seriously interfere with the child's rest. If the minute 



s^'MPT()MS. 305^ 

vesicle is punclured tlie degree of itching- is decidedly 
ameliorated. They are made decidedly worse hy filth. 

Respiratory Symptoms. — Catarrhal involvement of the 
respiratory mucosa is a cardinal feature of the exudative 
diathesis. A tendency toward recurrence of these attacks 
is their most significant characteristic (the so-called "re- 
current sibilant bronchitis" of American writers). ' Rhinitis 
is common as well as pharyngitis and follicular tonsillitis 
and chronic tonsillar enlargement. Bronchitis, which not 
only, as just stated, frequently recurs, but which is likely 
to become subacute or chronic, is constantly seen. These 
frequent infections are nO' doubt responsible for the many 
children who present enlargements of the submaxillary and 
cervical lymphatic nodules. The majority of these enlarge- 
ments are probably tubercular. This is true also of the 
enlargements so commonh^ found at the roots of the 
bronchi. Infection in both instances is the result, undoubt- 
edly, of the frequent "colds" to which patients with the 
exudative diathesis are subject. This disease therefore be- 
comes one O'f considerable importance in the consideration 
of the prophylaxis, not only of glandular, but of pulmonary 
and of all other types of tuberculosis. 

"Bronchial asthma," or recurrent sibilant bronchitis, 
to which reference has already been made, a disease but 
little understood as to its etiology and certainly less so as to 
its therapeutics, is regarded by the Germans as being, 
especially in infants and young children, a neuropathic 
expression of the exudative diathesis affecting the bronchial 
mucosa. Right or wrong, it matters little as long as a new 
thought with reference to this vicious and puzzling malady 
is suggested. The diet therefore, as indicated later, should 
be intelligently handled. Perhaps, then, this disease may 

20 



306 EXUDATIVE DIATHESIS. 

offer another example of a serious affection yielding to a 
simple remedy which has long been close at hand, but which 
has remained unrecognized. 

Digestive Symptoms. — Lingua geographica (Fig. 47) is 
a common occurrence and is prima facie evidence of the 
presence of the diathesis. It is a thickening of the epithelium 
covering the tongue, and assumes the form, of a whitish 
elevation which changes in shape from day to day. Oral 




Fig. 47. — Lingua geographica, 

infections, as stomatitis and canker, likewise occur. The 
breath is heavy and often has a sweetish odor. The bowels 
are commonly normal, but may be constipated. The thin, 
d3^speptic stools of the newborn, breast-fed baby are re- 
garded by Czemy as due to. this diathesis. My own experi- 
ence wo'uld lead me to believe that this is not so in the 
majority of instances. The intestinal mucus may re^^eal 
eosinophiles (eosinophilous stools). Dyspeptic stools are 
commonly met in the weak, underfed infants who suffer 
from eczema intertriginosum. 



DIAGNOSIS AXl) I )l I' I- I<:RKNT1 AL 1)1 ACiXOSIS. 307 

The Blood and Nervous System. — Sonic of lliese l)al)ics 
exhibit symploniatic aiicMiiia. In most all, the cosiiiofyliilcs 
are increased to as high as from 20 to 30 per cent, h^spe- 
cially is this noted in cases with eczema. The connection is 
not clear. Whether the eosinophilia depends upon the 
eczema, or both the eczema and the eosinophilia. depend upon 
the underlying- factor, has not been determined. Various 
nervous symptoms appear from time tO' time, as night- 
terrors, chorea, urinary incontinence, etc. These are not to 
be reg-arded as the direct manifestations of the diathesis, but 
occur from other exciting factors operating upon a weakened 
system. 

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 

From all that precedes, the physician will immediately 
recognize that he has seen, and is seeing' daily, mau}^ of these 
infants and children. In the past he has failed to classify 
them, failed to> recognize that, without a correct conception 
of the underlying diathesis, liis attempts to thoroughly cure 
these babies O'f eczema and other infections have been sig- 
nally fruitless. On the other hand, he has succeeded blindly, 
applying his remedies empirically, but without the stimulat- 
ing effect upon himself which comes from doing things for 
a reason. Granting that, even with the recognition of the 
exudative diathesis as a clinical entity, much concerning 
its intimate nature remains lacking, we are at least provided 
with a basis for correct reasoning. Consequently with an 
attempt toward a correct therapeutic regime we are rewarded 
in some very obstinate cases with brilliant results. There 
remains nothing from which it is necessary to distinguish 
this diathesis. 



308 EXUDATIVE DIATHESIS. 

PROGNOSIS. 

As before stated, the severity of the manifestations of the 
diathesis varies constantly without the influence of external 
agencies. The substitution phenomena already mentioned 
must be borne in mind. Eczemas are rarely fatal, although 
they may be, especially in the presence of severe secondary 
infection. I have seen fatal pyemia result. The outlook 
in respiratory conditions depends on their severity and fre- 
quency and the general condition of the patient. The pos- 
sibility of tiiberailar infection must be remembered. Fre- 
quent attacks of follicular tonsillitis lead to chronic hyper- 
trophy and cardiac disease. The possible extension oi the 
effects of the diathesis intO' adult life, in the shape of rheu- 
matism, eczema, gout,' diabetes, asthma, and other affec- 
tions of undoubted metabolic origin, is not at all unlikely. 

TREATMENT. 

Prophylaxis. — A change from the city tO' the seashore or 
tO' the country is of supreme value in hastening the cure. 
The utmost cleanliness should be observed in handling the 
eczemas. Even without any evidences of skin involvement 
the latter should in every way be thoroughly cleansed, 
properly dried, and protected from^ infection and filth. The 
proper care of anal and urinary discharges is particularly 
important. I have learned to appreciate the value of daily 
inuncticns of cold cream for purposes of cleanliness, instead 
of water, in cases where the skin exhibits the least irritation 
or is already involved. 

Underfed Infants with Eczema Intertriginosum and 
Eczema Universale. — In the breast-fed it is necessary to 
add protein and salt to the diet. For this purpose, while 
continuing the breast, either plain sodium chlorid, 15 



TREATMENT. 309 

g'ranis daily, are given, or the same aiiKJunt of "emsersalz" 
(equal parts of NaCl and NaHCO;/). This is given with 
Larosan or Nutrose. The former, as previously stated, is 
calcium casein and the latter is sodium casein. These prc])- 
arations are added to water or diluted milk, in which the salt 
is also- placed. They may be sweetened if necessary with 
saccharin. They are g-iven for every other feeding. Locally 
fullers' earth is applied to- the skin lesion with xevy good 
effect. 

In artiiicially fed children who are under weight, reduce 
the fat and feed the child with eiweissmilch or Larosan 
made up with milk, whole or diluted. After the dyspeptic 
stools become normal a formula low in fat and containing 
starch- or a cereal- water or gruel may be substituted. 

Locally if the lesions are at all moist the application of 
fullers' earth is followed by a happy effect. On the other 
hand, the preparations of tar serve well in many instances. 
In seborrhoea capitis nothing does quite so well as a thor- 
ough cleansing with tincture of green soap, each morning, 
subsequent to the application of the following for twenty- 
four hours : — 

Ac. salicylic gr. vj-x. 

Ung. aqu?e ros?e or lanolin Bj. 

Under the influence of this simple ointment the cracks of 
eczema seborrhoeicum and of eczema intertriginosum speed- 
ily disappear and the infiltrated areas are made softer, less 
thick, and more pliable. 

Overfed Children with Eczema of Head and Face. — 
In these cases the total amount of food must be reduced as 
-d'cll as the quantity of fat and carbohydrate. These chil- 
dren should be fed almost exclusively on a diet consisting of 
vegetables, cereals, and eggs. Some children exhibit an 



310 EXUDATIVE DIATHESIS. 

intolerance for egg-albuniin and are made worse thereby. 
This may be determined in some cases by performing a test 
upon the skin exactly as the von Pirquet tuberculin reaction 
is done, except that egg-white is rubbed into the scarifica- 
tion instead of tuberculin. If the child is sensitive to this 
form of protein an area of erythema will surround the scari- 
fication upon which the substance was deposited (Allergy). 
Very little, if any, milk should be given. With some babies, 
even eggs must be omitted. If milk is used at all, it is best 
given skimmed. In the dry forms of eczema the ointment 
above detailed is of service. 

The zi'et types of eczemas do well on eczcina soup, which 
must be administered for from four to eight weeks. This 
soup is made as follows : Coagulate i litre of milk. Allow 
the whey to thoroughly drain off. Finely comminute the 
curd by pushing it through a hair-mesh sieve. Add it to 
200 grams of whey and further add sufficient water to make 
I litre, and sweeten with i tablespoonful of cane-sugar or 
I grain of saccharin. 

Marked amelioration is invariably noted after the ad- 
ministration of this preparation for just one week. It is 
well now to make use of additional carbohydrate and some 
vegetables and a cereal. Spinach, mashed carrots, stewed 
celery, stewed onions, oatmeal, farina, and cream of wheat 
are examples of the types of food to be allowed. The 
extra carboliA'drate should consist of either cane-sugar or 
some preparation of malt-sugar. 

Locally, when the eczema becomes dry, a tar ointment 
should be employed. 

Czerny, besides recommending a chang'e in climate, 
orders the following regime for a child weighing 8 
kilograms: — 



TREATMENT. 311 

A.M. — A sini[)le l)iscuit cooked in lOO i^ranis of milk. 
FoTenoon. — 200 grams of wliole milk and lliin (jatmeal- 

gTuel, half and half. 
Noon. — Soiip and vegetables. 
Afternoon. — 200 grams of whole milk and thin oatmeal- 

grnel, half and half. 
P.M. — 100 grams of whole milk, thickened with cereals. 

In severe cases the milk may be still further 

reduced. 

Recurrent Bronchitis. — It has been possible in se\'eral 
instances to cure and to pre\ent a recurrence of attacks of 
bronchitis, associated with (h'spr.ea and sibilant rales, by 
adopting the following routine: In the beginning milk, 
buffer, and sugar are entirely excluded frojii the diet. 
Dependence is placed entirely upon vcgcfahlcs, cereals, and 
meats zmfhouf fat. Raw and stewed fruits are not per- 
mitted. Sweetening" is obtained by the use of saccharin. 
The bow^els are kept regular by enemas and by mineral oil. 
All external sources of irritation, whether physical or 
psychical, are avoided. An open-air existence must be 
secured, and regular bathing, provided there be no eczema, 
must be practised. Very gradually the forbidden articles 
of food are added to the diet, one at a time. At the first 
suggestion of a recurrence, however, they are again rigidly 
excluded. It has been possible to demonstrate almost abso- 
lutely the influence of diet upon the recurrence of attacks, 
in several instances, and in others it has been possible to 
demonstrate the negligible effect of season. Certain chil- 
dren who have each winter suffered from recurrent bron- 
chitis have been kept entirely free when the diet has been 
rigidly enforced. 



312 EXUDATIVE DIATHESIS. 

Supposing that the metabolic disturbance results in an 
acidosis from the effects of which the bronchitis arises, the 
use of from i to 2 drams of bicarbonate of soda, scattered 
throughout the food each day, has been practised with good 
eft'ects. Other alkalies, like potassium or sodium acetate or 
citrate or sodium salicylate, are commonly administered in 
conjunction with the dietary treatment. During an attack, 
use is sometimes made of small doses of tincture of bella- 
donna, with good effect. 



I 



CHAPTER XII. 
PYLORIC OBSTRUCTION. 

Synonyms. — Congenital pyloric stenosis. Congenital hy 
pertrophic pyloric stenosis, Pylor()S])asm, etc. 




Fig. 48. — Showing pyloric obstruction. 

Nature. — In order that this affection may be the better 
understood it appears to me that the synonyms aboA-e should 
be omitted from medical literature and that the disease 
should be known as (a) infantile pyloric obstruction com- 
plete and (b) infantile pyloric obstruction incomplete. In 
all cases there is an obstruction at the pyloric ring 
(Fig. 48). This prevents the onward movement of the 
gastric contents into the duodenum from taking place, either 
completely or incompletely, depending upon the degree of 

(313) 



314 PYLORIC OBSTRUCTION. 

obstruction. With this coiiception, a better understanding 
of the chnical phenomena is available and a more rational 
therapeutic classification is also pO'Ssible, as we shall see. 

PATHOLOGY AND ETIOLOGY. 

Predisposing Factors. — Age, sex, neurotic parental tem- 
perament have all been studied statistically as to their bear- 
ing on this condition, but they serve no purpose in either 
prevention or in cure, and will not, therefore, be further 
discussed. 

Active Factors. — The cause of the obstruction in every 
case is a narrowing or a practical obliteration, of the lumen 
of the pylorus by (a) hypertrophy of the pyloric fiuiscle or 
(b) spasm of the pyloric muscle or (c) a combination of 
both hypertrophy and spasm. The last is, in; all likelihood, 
most commonly present. Bearing these underlying anatomic 
features in mind, it is perfectly easy to understand the suc- 
cession of symptoms characteristic of the two^ types of this 
affection, which are met clinically. Reference will again be 
made to this point. 

Much as a clear understanding as to^ the ultimate direct 
cause of the hypertrophy or of the spasm would assist in 
adopting perhaps antenatal or postnatal preventive meas- 
ures or even curative ones, at present, no' definite data bear- 
ing on this point are available for practical purposes, 
although many theories, ingenio-us and otherwise, have been 
offered. These I shall not discuss, for a medley of diverg- 
ent opinions cannot possibly serA^e any useful purpose and 
will only yield confusion. My view, based upon the obser- 
vation of two do'zen or more cases, is that in essentially all 
of them the initial condition -icas spasm, and that hyper- 
trophy follozued as the residt of intense, continuous musctdar 



PATHOLOGY AX I) ET\()\AHA\ ^l^ 

activity, and I am, beginning- to feel that perhaps S(jmething, 
either in the mother's milk or in the intestinal and gastric 
juices or in the resultant of the activity between these juices 
and the milk, is responsible for the initial spasm. There- 
fore T believe that our investigations in the future as to the 
fundamental cause of the primary spasm will have to Ijc 
sought in this direction. l\[y reasons for this belief are: 
{a) most cases do not show symptoms immediately after 
birth, hut perhaps anyzuhere from two to four weeks; (b) 
the degree of spasm is not akvays the same in a single case, 
indicating that the local irritant of the nervous mechanism 
of the pylorus varies in its intensity; (c) complete non- 
operative recovery is possible, the symptoms of obstruction 
sometimes subsiding zt'ith comparative suddenness and this, 
in some cases, has been hastened by a change in diet. For 
our purpose, at present, it is sufficient to remember that the 
pylorus is either completely or partially obstructed, and that 
either one of these conditions, may be brought about by 
spasm, hypertrophy, or both. Thus it is conceivable that the 
spasm may be so intense and permanent as to cause complete 
obstruction, just as well as one may imagine a partial ob- 
struction due to hypertrophy alone (rare) if the hyper- 
trophy were not sufficient tO' entirely occlude the lumen. 
Hypertrophy per se may cause complete obstruction. So, 
too, the spasm may be intennittent when either alone or 
combined with hypertrophy, causing the obstruction to be 
intermittently complete and incomplete. Clinically we shall 
see that this is well borne out. Thus any combination oi 
spasm and hypertrophy may exist. The essential thing, 
hozcever, as far as subsequent treatment is concerned, is to 
study these cases clinically, disregarding in a sense the 
pathology, and to determine in the individual case whether 



316 PYLORIC OBSTRUCTION. 

the obstruction he complete or incomplete and, if the latter, 
zi'hether enough food passes to sustain life and to zvarrant a 
continuance of non-surgical treatment. Reasoning from 
these data, the symptomatology may be rationally discussed 
as folloAYS : — 

SYMPTOMATOLOGY. 

A. Complete Obstruction. — This is the less common of 
the two varieties. Vomiting results directly from the ob- 
struction. The food cannot get through the obstructed 
pylorus, so it is ejected through the cardia, after remaining 
in the stomach a variable length of time. It is the latter 
phenomenon which often causes confusion and error. One 
might imagine that if the pylorus is completely occluded the 
vomiting must occur after each feeding. This is not so 
because the stomach becomes dilated and its capacity may 
become enormous ( Plate, XIII). Thus vomiting may occur 
but three to four times or less, per diem. Especially is this 
true after the condition has existed some weeks. Therefore, 
the amount vomited is important. It may represent three or 
four or five or more feeds, and be sour and bacl-smelling. 
Vomiting may, however, occur after each feed. 

The nmnner in which the food is ejected is characteristic. 
It is forceful, propulsive, projectile! The vomitus literally 
shoots out of the mouth, and often through the nostrils as 
well. If very acid it may cause the infant tO' cry or set up a 
coryza. The stream may reach a foot or more beyond the 
crib. It occurs without nausea, gagging, or any apparent 
effort on the part of the infant. Vomiting may commence 
immediately after birth. More often it is delayed until the 
second or third week. It is one of the prominent causes for 
removing the infant from the breast when the fault lies not 



i'L\'ri': Mil 




Showing stomach-tube /;/ situ in case of intense gastric 
dilation. The tip of the tube is opposite the right superior spine 
of the ihum and the lower border of the stomach is at the brim 
of the pelvis. This case made a complete non-operative re- 
covery. 



S^■MPT()MAT()L()(i^■ 



ir- 



Z\7 



with the maternal milk, l)ut clcpciuls upon an unrccnj^mzed 
obstniction at the pylorus. The further history of these 
babies usually is that they are placed upon an indifferentlv 







































/ 


r^ 


lOIDS 














'/ 


f 
















/ 








albs. 16 


a 






/ 


/ 










■i 

if 

7 lbs. ' 


1 


/ 


/ 


/ 
















^b 


















Weeks 
















\ 9 



Fig. 49. — Weight curve in a case of complete or surgical 
pyloric obstruction, a-h, continuously downward course (char- 
acteristic of this type of obstruction), resembling the crisis of 
'pneumonia temperature curve; h-c, upward course (gain) after 
posterior gastroenterostomy. (Original case. Operation by 
John B. Deaver, M.D.) 

modified coavs* milk or upon a patented food without any 
relief from the vomiting". Such a history, obtained in a 
breast-fed baby, should always create the suspicion of 



318 



PYLORIC OBSTRUCTION. 



pyloric obstruction. In my experience it has been sO' con- 
stant that I haA^e come to regard it almost as a part of the 
clinical picture of the disease. 

Constipation. — Think again of the pylorus completely 
occluded, either from spasm, hypertrophy, or both. All the 



12 3 4 3 

Months 
Weeks i 3 s 7 a 11 13 ts n 19 zj 23 


6 T S 3 iO 11 

25 27 20 31 33 3 5 37 3 41 4; 45 47 


T" 









_ , 












ySi, ' ' 




_ _ _ _ . _ J.^ 




.„-" ""■ " s^/ _. 




12 - s^i-i!: ::::::: : 




"I ::: z ^^^ .. _ ..i- . 




<7>^2 




11 ::.... ^\ij.-. t 




1^ Cv IZ 




u " «v- - 7 - t - - - 




' ' 3 JO- t f.- - 




.„ oCi- - -- y. - ~ 








t 2 




BirtVi L. ^ t " it " 




Q^" -~t.. :i: ::_:_. 




^ \ / / 




\ t I 




^ L U _ _ 




fK.Xl _, _-. 




° 2 t 




li\- - > - - 




^ y - - 








7 — - — ^^ 




:^ _ ^^ _ __ 




. it », : 












Pounds \J_ T^^,,Pf: 


cient amount of nourishment 


^ j: msuii] 


r-. 1 1 i 1 1 1 

Weeks 1 3 5 7 N9 U 13 15 17 19 21 


1 M 1 1 M 1 1 1 1 M 1 1 1 1 1 1 1 1 1 1 

23 25 27 29 31 33 35 37 39 41 43. 45 47 



Loss of Weight during period of observation for four days just 
preceding operation 

Fig-. 50 shows effect of posterior gastroenterostomy on 
weight curve in a case of complete pyloric obstruction. Note 
continuously downward course of weight curve before opera- 
tion, as in Fig. 49. Original case. Operation by Francis T. 
Stewart, M.D. (H. Lowenburg, N. Y. Medical Journal, Feb- 
ruary 11, 1911.) 



food is A'Omited. None passes into- the duodenum and 
thence into the intestines. The reason for constipation is 
clear. It is complete — absolute. It is obstipation. The 
bowels moA'C rarely, it is true. The movements consist of a 
discharge of bile-stained mucus. They have no bulk. They 



S\MrT()MAT()L()(]\'. 



/ 

3W 



contain neither curds nor digcstcd-milk feces, l)ccausc none 
can come throug-h. 

Weight and Strength. — P^rom the very onset of syni])- 
toms the weif>-ht curve tends proo^ressively down ward. It is 




1^'ig. 51. — Visible gastric peristalsis. 

continuously depressed. There is no hesitation, nO' retrench- 
ment, no stationary weight. The loss may not be suddenly 
great. It is rarely so. It is, however, continuotLsly doimi- 
zwird. Thus an infant weighing 7^ pounds at birth, for 
instance, may lose ^ or j4 pound by the end of the first 
week after the onset of symptoms. If this is repeated dur- 



320 PYLORIC OBSTRUCTION. 

ing the second and third week, the possibiHty o;f complete 
obstruction or practically complete obstruction becomes a 
certainty. The weight curve in these cases resembles in a 
sense the curve seen in the crisis of pneumonia (Figs. 49 
and 50; compare with Figs. 52 and 53). The effect of 
edema on the weight curve will be considered later. 

The infant's strength for obvious reasons becomes pro- 
gressively less. Its movements become weak; its cry lacks 
force and it lies quietly in bed unless disturbed. 

Visible Gastric Peristalsis (Fig. 51). — This is the most 
mteresting as well as the most important symptom from a 
diagnostic viewpoint. Bearing in mind again the obstruc- 
tion at the pylorus (Fig. 48), its method of production is 
readily understood. The stomach endeavors, as it were, to 
pass its contents onward into the duodenum. It cannot do 
so. This causes the peristalsis of the stomach to become 
exaggerated. The involuntary muscle is stimulated in an 
effort to overcome the obstruction. The waves of contrac- 
tion become greater and are seen in the epigastrium, pass- 
ing from left to right. A globular mass which can be pal- 
pated will appear under the lower left costal margin. It 
will lazily pass across the epigastrium. Before it progresses 
very far another will form at the original site and slowly 
follo'ws the first, which gradually disappears under the right 
costal arch, while perhaps yet a third is forming under the 
left border. So it will be seen that two or three globular 
masses are slowly following one another from left to right 
across the epigastrium. The appearance has been likened to 
the rolling of two or three balls under the skin. The masses 
represent sections of the contracting stom.ach. 

The gastric peristalsis is not constantly visible. In the 
beginning it may not be seen at all because emaciation has 



pi.A'i'i-: xi\^ 




Practically complete obstruction. Operation. Recovery. Imme- 
diately after the administration of the bismuth. 



II. ATI-: XV 




One hour after the administration of the bismuth. Xone of 
the chemical has left the stomach. 



I'LATI-: W I 




Three hours later, Xo bismuth has left the stomach. Xote 
the thickened pylorus (P) and how the bismuth shadow stops 
abruptly there. 



i'LATi': Wll 




Six hours later. Xo bismuth has left the stomach. Xote 
the stomach was photographed while undergoing contraction 
(C). Note the lower border of the stomach to be opposite 
the brim of the pelvis. Xo bismuth has passed beyond the 
thickened pylorus (P) . 



I'LATi-: will 




The next day, about nineteen hours later. Bismuth still in 
the stomach. Very little in the small intestines and sigmoid. 
The amount is practically negligible. Infant has vomited some 
of the bismuth. 



1 



'LATI-: Xl\ 




Comet-like appearance of the bismuth shadow at the pylorus 
in cases of complete obstruction. This appearance is almost 
constant and is very characteristic of this type of obstruction. 



I 



SYMPTOMATc )!,()( ;^^ 321 

not become sufficiently adxanced to permit the moNement U) 
alter the normal appearance of the surface of the u|>]k.t 
abdo'tnen. It may also be invisible when the stomach is 
empty, as immediately following a severe sjKdi of vomiting. 
Just preceding this event, however, it i^ commonlv accen- 
tuated. It is often present during sleep. // may he in- 
augurated by the giving of food or drink or by tafyping 
lightly upon the epigastrium KntJi the back of the middle- 
finger. A few moments may elapse l)efore the cfMitractions 
commence to appear. Therefore, zchen searehiiig for this 
symptom it is unsafe to conclude that it is absent u)dess the 
maneuvers above are employed and unless the epigastric 
area be visualised at least for from ten to fifteen minutes. 

In some cases the pain associated with the contractions 
is SO' intense as to. cause the infant to cry. 

Rarely the movement of the visible gastric peristalsis is 
seen toi be reversed, i.e., it passes from right to left. All 
these instances, however, must be carefully distinguished 
from visible peristalsis due to contraction of the transverse 
colon. This is occasionally met in thin subjects and in 
cases of obstinate constipation or of organic obstruction of 
the large intestines. 

Dilated Stomach. — At first the muscle-fibres undergo 
hypertrophy. Later they become thinned and the degree of 
gastric dilation may become enormous (Plate XIII). As a 
rule the lower border of the stomach may be readily seen 
through the thin abdominal wall. At first it does not reach 
below the t,mibilicus, and the upper abdomen alone is dis- 
tended while the lower portion of the belly is flat on account 
of the collapsed condition of the intestines, into which no 
food has entered. Later as the dilation increases the lower 
border of the stomach reaches far below the navel. In fact 

21 



322 PYLORIC OBSTRUCTION. 

it may reach the pelvic brim (Plate XIII). This is readily 
determined by inspection and can be confirmed by palpation 
and X-ray studies. In this enormous degree of gastric 
dilation is found the explanation why, in advanced cases 
especially, vomiting need not and does not occur after each 
feeding and may appear but a fev^^ times each day. 

Palpable Pylorus. — The pylorus is thick and hard 
(Fig. 48) ; whether fromi hypertrophy or from spasm or 
both, matters not. The abdominal wall is thin. Therefore 
it is possible to palpate the pylorus. It is commonly felt as 
a hard object, aboiut the size of a small olive, a little above 
and to the right of the umbilicus. It is best felt by placing 
the warm hand gently upon the abdomen, employing the 
middle-finger as a searcher by gently but firmly pressing it 
into the abdominal wall. If the abdominal muscles are 
made rigid by crying or straining, palpation cannot be suc- 
cessfully accomplished. In order to overcome this the ex- 
amination should be made while the infant is placed at the 
breast, or while it is receiving other food or drink, or some- 
times during sleep. The abdominal wall must be thoroughly 
relaxed. 

In some cases of complete obstruction it is impossible to 
palpate the pylorus during the early stages of the case on 
account of the comparatively thick layer of adipose tissue, 
only slight oir no loss of weight having occurred. The 
position of the pylorus is not always constant. It is occa- 
sionally found close to the lower border of the liver, near 
the median line, but above the umbilicus. Where a great 
amount of gastric dilation has ensued it may be found low 
down and close to the pelvic brim tO' the right of the median 
line. 



/ 

SYMPTOMA'J'OLOGY. 323 

X-ray Studies. — These slionld he made in all eases. 
While iiiuieeessary for a rliiiicd/ didsj^iiosis af ohstntetioji. 
per se, they aid materially in disliiii^iiisliini^ complete fraiii 
incomplete cases, arid are often of indue iu assistiui^ to 
determine zvhether the treatment shall l)e suri^iail or )uni- 
surgieal. For making- these studies nnlv hisuiutii sut)car- 
bonate should he employed, and should he administered 
througfh a tube. In cases of complete ohslruclion it will he 
found that no^ bismiuth leaves the stomach tn enter the in- 
testines, after a period of twenty-four hours. During;' thi^ 
time a series of nO' less than eight or ten ex])<)sures should 
be made, commencing immediately after the admimstration 
of the drug and ending not less, in an}- case, than sixteen 
hours after this time. This will insure sufficient time to 
permit the smallest amoimt of bismiuth to pass (Plates Xl\', 
XV, XVI, XVII, and XVIII). 

In cases of complete obstruction I have noticed that the 
bismuth shadow assumes a "comet"-like appearance almost 
immediately after administration. I regard this as highly 
significant (Plate XIX) of this type of obstruction. 

Charcoal Test. — Administer lo grains of either ammal 
or wO'O'd charcoal throaigdi the stomach-tube, to the near end 
of which is attached a syringe wdiich contains the charcoal 
suspended in an ounce or two of water. Slowly inject it. 
Make a note of the hour of injection. Have the nurse do 
the same, each time she changes a soiled diaper. In cases of 
complete obstruction no charcoal zeill appear upon the 
diaper. In the mean time considerable charcoal will be lost 
each time the infant vomits. At the end of twenty-four 
hours wash out the stomach. The z^'ashiugs z^'ill coutaiii 
charcoal — showing conclusively gastric retention and the 
non-entrance of aliment into the intestinal canal. 



324 PYLORIC OBSTRUCTION. 

Temperature. — This speedily becomes subnormal unless 
external heat is employed. If infection occur it becomes 
elevated. These infants become readily infected (see Com- 
plications) . When starvation becomes marked the tempera- 
ture rises and may reach 104° F. before death. I have also 
witnessed a sudden rise which I cannot explain follow 
immediately after stomach washing. It speedily disappears, 
however. The poor resistance of these babies is frequently 
emphasized by their death from pneumonia just abO'Ut at 
the end of the disease or immediately after recovery. The 
temperature rises very high and death may ensue before the 
signs of consolidation become evident. 

Urine. — The urine exhibits no^ changes of interest 
except toward the end in cases which have remained un- 
treated and in wdiich vomiting has been unduly severe. 
The tissues become parched for the want of water. The 
urine then is scant, dark, highly concentrated, sharply acid, 
and excoriating. Urates may be deposited upon the diaper. 
A faint trace of albumin is present and microscopically 
kidney debris and other organizeda substances are found. 
Therefore, other things being equal, it may be correctly sur- 
mised that a free flow of normal limpid urine is a favorable 
sig-n. 

Edema. — This is not directly a part of the clinical pic- 
ture of pyloric obstruction. It may, perhaps, be better 
classified as a complication. It is emphasized here, how- 
ever, because its onset is so insidious and because it fre- 
quently passes unnoticed, but principally because it is 
responsible for a more or less abrupt increase in weight 
zi'hicli is erroneously regarded as a favorable sign. The 
additional weight is not fat, but water. I have seen this 
error made and a favorable prognosis recorded when death 



SVMPT()M.\T()L(JGV. ^25 

was but a, few days away. // is a very iiiifuvoniblc syuip- 
toin. It occurs aloug tcjward the cud of severe cases in 
which vomiting has been unusually constant. The insteps 
and the loiwer legs are first affected and gradually it spreads 
upward, rarely, however, passing alcove the knees. Its 
method of production is little understood, notwithstanding 
an overabundance of theorizing. 

B. Incomplete Obstruction. — This type is more comuKtn 
than that of complete obstruction. There are, howe\er, all 
grades of this form which clinically must be differentiated. 
Many of them approach in severity cases of complete ob- 
struction, as we shall see, and must, like them, be treated 
surgically. Therefore, the distinction between complete 
and incomplete obstruction must not be regarded as final, 
but, therapeutically, at least, the classification of surgical 
and of non-surgical must be made as well, for many cases 
of incomplete obstruction require operation. In fact, I 
believe the number of this type of case is daily increasing, 
as the mortality from operations is steadily becoming less 
and as the cases are receiving' closer clinical study. 

Vomiting. — This partakes of the nature of the vomiting 
in cases of complete obstruction, except in vei'y mild in- 
stances wherein the spasm occurs with some intemiittency. 
Here the intervals between attacks may at times be more 
than a day or two, to be renewed again with intense vigor, 
when the degree of spasm increases. 

Constipation. — Bearing in mind again the obstruction 
at the pylorus and that it is not complete, one can readily 
understand that some of the aliment passes and that there- 
fore constipation, while present, is not absolute. The si:;e 
and the frequency of the movements vary directly as the 
degree of ohstrnction, zchich also determines the severity of 



326 



PYLORIC OBSTRUCTION, 





- 


V 








' 






\ 


N, 


Fig. 52 is less 
g. 53 shows the 
le line resembles 
ued fever. The 
ded, the gradual 
gain of several 








5 
















^ 


"^ 


.ruction. 

53. Fi 
ases. Tl 
r contin 
ely recor 

sudden 


\ 






\ 






s 




( 




Dric obsl 
in Fig 

irgical c 
or othe 

alternat 

e was a 


1 






V 








< 

/ 


\ 


al pyl 
d than 
non-si 
yphoid 
being 
k ther 


/ 






1 






9 


■V/^E ^ G ^ 






\ 


non-surg 
more ra 
ncomple 
gium of 
and gai 
venth w 








1 










< 


Dmplete 
dual, is 
ases of i 
the fasti 
ht losses 
the ele 


\ 






« 






1 










\ 


(J ^ u 'OD u 


1 


i^ 







•" bo G o ^ i; 

^ :^ '-S ^ i < 


^ 


.^ 








\ 


case 
ight, w 
obtai 
ure cu 
for we 
pward. 
ned. 




\ 
















\ 


- 5 S E 2 £> = ! 

G a-* c« bo .t5 






< 


) 








^ 


irts o: 
;ain in 
ight c 
temp 
station 
, bein 
as ma 












/j 




sight chi 
nd the g 
ristic we 
n in the 
•emains . 
however 
which w 


, 1 


i 


\ 1 


i 

3 

1 


h 




IT) 

bb 


^■^^'-'^;^;,r'^" 


1 


Fig. 53 


^j5~ 




\.J 


Weeks 

w 

severe a 
characte 
that see 
weight 1 
course, 
ounces. 



SYMITC)MAT()L()(,V. ,^27 

the tzvo symptoms — voDiitiiio^ and 7castin^i^. Tlicsc, in coni- 
mo'ii with constipation, form a trinity of sym|>toms wln'cli arc 
closely interrelated, and winch possess considcrahlc \>Vi*u;- 
nostic import. The movements are nsnally small and dry. 
Not being- of sufficient size to stimulate peristalsis, they lie 
in the lower bowel so long that they become inspissated. 
The bowels move, on the average, once every three or 
four days, a suppository or tlic clinical tlicrniomck'r he-ing 
necessary to secure an evacuation. The movements consist 
of milk feces and mucus, and often contain small curds 
which in themselves are conclusive exidence that llie 
pylorus is not entirely occluded. 

Weight and Strength. — A common clinical type of in- 
complete obstruction presents a weight curve which is 
radically different from that of complete obstruction. Vox 
developing this fact, I believe that I may claim originality, 
for I have no' knoavledge of its description having been pro- 
posed by any other author. Before describing this cur\c it 
is necessary to state that there is one type of case, howe\er, 
of incomplete obstruction of which this is not true, \iz., 
those instances in which the passage through the pylorus 
is so small that but little aliment passes, and for all intents 
and purpoises, clinically at least, the case presents the fea- 
tures of complete obstruction, and must be so regarded 
therapeutically. It would perhaps be better to say that this 
latter type oi Aveight curve belongs to su.rgical cases rather 
than to a certain type of incomplete obstruction, because 
all cases wdiich present it must be operated upon and under 
it are included as well all cases of complete obstruction, as 
has been already indicated (Figs. 49 and 50). Figs. 54 
and 55 represent the correct manner of weighing an infant. 

The curve in typical, non-operative, or non-surgical 



328 



PYLORIC OBSTRUCTION. 



incomplete cases suggests the line of a continuous fever 
with slight remissions and elevations (Fig. 53; compare 
with Figs. 49 and 50). Thus the infant loises a few 
ounces, — say, two or three. The next day he gains one 
or tAvo ounces. The day following neither loss nor 
gain is recorded. This may continue for a day or two. 
Again a slight gain or a slight loss occurs, so' that at the 



4 


^^^^^£m|mB| " -^^ 


g. 



Fig, 54. — Weighing the baby. First ascertain the weight of the 
towel. (Fairbank's scale, No. 554.) 



end of a week the weight is the same or there is noted the 
loss or the gain of an ounce or two. The curve may remain 
stationary for twO' or three; weeks, with slight losses or 
gains recorded in the daily estimations. These have a 
direct relation tO' the severity of the vomiting and the con- 
stipation. If spasnii is worse for a few days, these are in- 
creased and with them is recorded a loss. As the obstruc- 
tion relaxes vomiting and constipation are less, and the 
lost weight is partially or wholly regained, with an ounce 
or so to spare. Therefore it can be appreciated how at the 



SVMrT()MAT(JL(J(j^'. 



/ 
529 



end of five or seven weeks after birth tlic weight has 
changed but httle, being somewhere between six and seven 
pounds, or there may be noted hut a slight loss of abrmt a 
half to three-quarters of a pound. A careful study of h'igs. 
50 and 53 will be of value in emphasizing this crucial 
chnical point of difference between operative and non- 
operative cases. 







^^^1 







Fig. 55. — From combined weight of baby and towel subtract the 
weight of towel to obtain result. 



Visible Gastric Peristalsis. — The description of this 
symptom^ under complete obstruction applies here, except 
that at times the intensity of the waves may be temporarily 
suspended only to return again with, increased vigor. 

Dilated Stomach. — The degree of dilation is somewhat 
less than in complete cases, although in severe types it may 
Teach to enormous proportions. After recovery, in non- 
operative cases too-, the normal outlines of the stomach are 
commonly recovered except in those cases which extend 
into childhood and to which reference will again be made. 



330 PYLORIC OBSTRUCTION. 

Palpable Pylorus. — The same causes which at times in- 
terfere with the successful palpation of a completely oc- 
cluded pylorus apply here. In addition, in those cases which 
depend entirely upon spasm and in which this phenomenon 
is intermittent, even when the abdominal wall is quite thin, 
the pylorus will not be palpable when it is relaxed. There- 
fore should this finding be reported negatively it does not 
exclude the diagnosis of either pyloric obstruction, com- 
plete or incomplete. In the latter instance it may be posi- 
tive the next day or within a few hours or even minutes. 
It ma}^ occur as the visible, gastric peristalsis, directly after 
the giving of food or drink or after tapping over the epi- 
gastrium, to disappear again. The feel of a pylorus', in 
spasm is just as hard as of one thickened by hypertrophy, 
only it may not be so constant. For this reason I do- not 
believe, as some authors teach, that every case in which the 
pylorus is palpable should be operated upon. I have had 
several non-surgical recoveries in such instances. This 
intermdttency is very common in partial cases and is sug- 
gestively diagnoistic of them. ^Vhere hypertrophy is present 
or where spasm is intense and permanent, this intermittency 
of palpability may be absent and the hard, olive-like pylorus 
may be easily and constantly felt. 

. X-ray Studies. — These indicate that more or less 
rapidly, depending upon the degree of obstruction, varying 
amounts of bismuth pass from the stomach into the intes- 
tines. The quantity which does pass and the time occupied 
furnish valuable data in assisting to determine the necessity 
for or against operation (Plates XX, XXI, XXII, XXIII, 
XXIV, XXV, XXVI, XXVII, XXVIII, and XXIX). A 
careful study of these plates will indicate that cases of m- 



DIAGNOSIS ANM) 1)1 !• !• i-:kl-:\'ri A I. 1)1 ACXOSIS. 33l' 

complete obstnictioii may 1k' cither siiri^ical ( I'latcs X W 
to XXIX) or non-suroical (Plates XX to XXIV j. 

Charcoal Test. — Charcoal passes through the pylorus 
and is therefore foiuid in the feces. The stomach washing's 
contain not any, little, or }niich charcoal, t\venty-t(mr hours 
after administration, depending- upon the degree of obstruc- 
tion and the severity of the vomiting'. ImmecHately after 
administration the caretaker is instructed to save and mark 
the time of each soiled diaper. In this way an idea is ol> 
tained as to the degree of obstruction and the rapicbty of the 
peristalsis. Therefore the X-ray findings and the charcoal 
test are valuable in permitting of an intelligent separation 
Qif the surg-ical from the non-surgical cases. 

Temperature. — Where the degree of emaciation is ex- 
treme, the temperature is subnormal. However, it is less 
difficult to maintain a rectal temperature O'f 98^/5° to 99° F. 
than it is in complete cases. 

Urine and Edema. — N'either of these possesses the same 
interest as in cases of complete obstruction unless, the degree 
O'f impatency be unusually severe. 

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS. 
A. In General. — Pyloric obstruction is not recogiiized 
because the average physician does not include it in the 
range of possibilities in reference to every case of wasting 
with which he comes in contact. He does not think of it at 
all. Its clinical features are so unique that it cannot be 
mistaken for anything else and cannot be passed by if it is 
at all considered. Nearly every case of unrecognized pyloric 
obstruction which I have seen in consultation has l^een 
called nwrasmus. The differentiation has already been dis- 
cussed under the description of the latter (Chapter IV, 



332 PYLORIC OBSTRUCTION. 

page 165). It is of sufficient importance, hoiwever, to^ em- 
phasize here that these two conditions resemble each other 
only in so far that in both wasting" is a piromiinent feature. 
Wasting in infancy, hozuever, must simply he regarded as 
a symptom and not as a disease, and the underlying cause 
must always be diligently sought. In this connection 
pyloric obstruction must always be considered as a very 
potent and probable factor of the nutritional bankruptcy. 

A very common occurrence is to consider that the 
vomiting is due to the breast milk. The infant is then 
promptly removed from it and a medley of formulas and 
patented foods are employed before the real cause of the 
disturbance is discovered. The practical constancy oi this 
error, as forming a part of the clinical history of this disease, 
has already been considered. Foir ordinary purposes it may 
be stated that mother's milk never causes vomiting, per se, 
unless the amount of fat is unu-simlly high for the individ- 
ual. More often among benign causes of vomiting in the 
suckling it will be fonnd that toiO' frequent feeding, pro'- 
longed nursing, nervous influences, impiroper training, and 
bad hygiene, singly or combined, are operative. Besides, 
the character of the vomiting is never propulsive. There- 
fore the following may be stated as a truism': That every 
case of persistent vo'miting, especially if projectile, occurring 
in a breast-fed baby, must be regarded as due ta obstructive 
pyloric disease until it can be proven that it is not. 

The only other factor responsible for projectile vomit- 
ing is cerebral disturbance. Here a history of dystocia or 
forceps pressure or visible head trauma will be in evidence, 
together with the results of cerebral pressure or irritation, 
as coma, palsies, or convulsions. An exception tO' the last 
occurred in a case seen at the Mt. Sinai Hospital, in which. 



DIAGNOSIS AKl) 131 1-|-I-:i<I-:\TI.\L DIAGXOSIS. 3'$^ 

following a history of forceps delivery, the infant suffered 
one or two attacks of convulsions. Vomiting soon sui)er- 
vened, but a careful physical examination revealed all the 
characteristics of pyloric obstruction incomplete. This 
merely emphasizes the need of bearing pyloric obstruction in 
mind in every case of vomiting as well as in every case of 



wastmg. 



Cyclic Vomiting. — I have proven to my own satisfac- 
tion, at least in one case in which the diagnosis of cyclic 
vomiting had been made, that the cause of the i>eriodic 
emesis depended upon the persistence of a mild intermit- 
tent pyloric obstruction. The child was 2j/ years of age. 
The history of incomplete pyloric obstruction in infancy 
was clear and X-ray studies, as well as the retarded passage 
of charcoal, made the diagnosis certain. Therefore, the 
suggestion is offered that all cases of so-called cyclic vomit- 
ing in youn^ children should be studied from this stand- 
point before they are regarded as being idiopathic, reflex, or 
metabolic. The case to which reference has been made re- 
covered completely under lavage. 

Obstipation or constipation, occurring as the result of 
congenital or other defects, may cause some confusion, espe- 
cially if there be associated reflex vomiting, so called. 
Bearing in mind the essential symptomatology of pyloric 
disease, an intelligent discrimination will readily be per- 
mitted. 

B. Complete Obstruction. — Depending directly upon the 
complete obstruction at the pylorus, the following ensemble 
of symptoms constitutes a definite clinical picture : Propul- 
sive vomiting, obstipation, loss of i^'cight and strength 
(persistent) , visible gastric peristalsis, dilated stomach, pal- 
pable pylorus; non-passage of bismuth subcarbonate from 



334 PYLORIC OBSTRUCTION. 

the stomach into the intestines, as shoimi by the X-rays; the 
non-passage of charcoal through the gastrointestinal canal 
and its recovery the next day in the stomach washings. 

C. Incomplete Obstruction. — This is characterized by 
propulsive voniiting; a variable degree of constipation; a 
gradual loss in zveight, zuhich may become stationary; 
visible gastric peristaltic zvaz-'es of variable intensity; per- 
manently or intermittently palpable pylorus; dilated stom- 
ach; the retarded but final passage of bismuth through the 
pylorus into the intestines; the passage of charcoal and its 
non-return or in variable but small amounts in the gastric 
zvashings, depending upon the degree of obstruction. 

By noting the amount of bismuth and of charcoal which 
passes, one is often permitted toi judge of the quantity of 
aliment which gets through, and is therefore able to con- 
clude roughly whether this is sufficient to sustain life. This 
materially assists one to properly catalogue the individual 
case as surgical or non-surgical. The differential data be- 
tween these two types of cases are systematically presented 
under the prognosis, page 338. 

COMPLICATIONS. 

Pneumonia may occur, rarely, as a direct result of stom- 
ach washing, due tO' inspiration of foreign material. These 
cases all do' poorly. High temperature, difficult to explain, 
may follow stomach washing. As has been mentioned, it 
speedily disappears. Edema has been noted. These in- 
fants, on account of their low vitality, bbar infection badly. 
I have seen a severe case of pyemia follow the undoubted 
infection of broniid papules. The eruption was profuse 
upon the scalp and face. Under the administration of a 
mixed streptococcic and staphylococcic serobacterin recovery 



PROG X OS IS. 335 

ensued. Sudden death occurs willioul apjjarcnt cause, as in 
cases of marasmus, after extreme emaciati.)n has i)crsiste(l 
for some time. 

PROGNOSIS. 

In g-eneral this depends u})on the i)r()mptness wiili wliicli 
a (h'agnosis is made, and ^vith wliich an intellif^ent therapy 
is adopted and conscientiously pursued. Xo half-way 
measures will bring results. Cases which are hawked from 
doctor to doctor or from clinic to clinic eventually succumb. 
For tbis reason I believe that, once the diagnosis is made, 
the physician should make a frank statement of the case 
to the parents, going into details as to the exact nature of 
the trouble, defining his attitude, telling them at l)est the 
case will be long drawn out, and that at any time, after a 
sufficient period of observation has elapsed, it may Ixxome 
operative. On this point, I believe that a week's observa- 
tion should permit of an intelligent and final opinion. 

The attention to details, the infant's environment, close 
adherence toi prescribed methods of treatment, strict loyalty 
to feeding orders, are all of unquestioned importance in their 
bearing upon the final outcome of the case. 

Of course, operation increases the immediate danger. 
However, the results after posterior gastroenterostomy have 
been so excellent that in selected cases it should not be too 
long- postponed. The operation must, however, l:>e done by 
an expert, and before the infant's nutrition and strength be- 
come too seriously impaired. Even as a dernier ressort it 
must not be refused, in cases which have been neglected. 
No case is hopeless, from an operative standpoint, until it is 
dead. Scudder and others report brilliant success from 
operations. My own operative cases include six: one, 
almost moribund, recovered after operation by Dr. Francis 



336 PYLORIC OBSTRUCTION. 

T. Stewart. Five others were operated upon by Dr. John B. 
Deaver: four made excellent recoveries; one died twenty- 
four hours after operation. This infant was edematous and 
emaciated when brought to the table, where it nearly suc- 
cumbed twice during operatioiu. Operation had been ad- 
vised as the only hope two) weeks previously, but was re- 
fused. The youngest case operated upon by Deaver was 3 
weeks of age. It made a perfect recovery. The oldest, 
operated upon by him for me, wa,s 8 weeks of age. It toO' 
became well. Sixty-three per cent, of my medical cases 
recovered. Of those which died some were unrecognized 
until it was too late, some refused surgical treatment, and 
still others were entirely neglected. I believe that if the 
cases treated medically are properly selected, the percentage 
of recoveries would be higher and would equal at least the 
operative results. The idea which I wish to^ convey is that 
in oiur study of this disease it should ever be our aim, to im- 
prove our knowledge as to the character of a non-operative 
and of an operative case. The line of distinction can be 
drawn, and I believe that none of these babies, if properly 
classified, other things being equal, need succumb. Even 
recognizing that operation increases the immediate danger, 
I believe that this risk should be assumed in more cases 
rather than to err on the side of attempting to treat surgical 
cases by non-surgical methods. It is my belief that the 
general mortality of pyloric obstruction would in this way 
be more materially reduced than if more conservative 
methods were pursued. 

What constitutes a surgical case? What constitutes a 
non-surgical case? Clinically all cases becon^e operative 
when sufficient aliment fails to reach the intestines. There- 
fore it follows that not only are all cases of complete ob- 



PLAT1<: XX 




Non-surgical incomplete pyloric obstruction. Bismuth in the 
stomach immediately after administration. 



I'LA'IM-; NX I 



# 







Two hours later. Much bismuth is seen in the small intestine, 
but also in the stomach. 



V 



IM..\'|-|-: xxii 




Bismuth still in stomach, but also seen in small intestine and in 
the ascendino- colon: four hours after administration. 



I'LATI-: Wll 




Much bismuth still in stomach, but also seen in the descend- 
ing colon and sigmoid; six hours after administration. Stomach 
should be empty. 



I 



I'LATI-: ,\.\l\' 




Eighteen hours later. Stomach should be empty, but 

still contains much bismuth. 



I'l-ATi'". ,\W 




Case of incomplete but surgical pyloric obstruction. Gas 
and bismuth in contracting stomach, immediately after ad- 
ministration. 



1 



I'LATI' XWI 




Bismuth in stomach, but small amounts scattered throughout 
small intestine : two hours later. 



PLA'l'l-: x.wii 




Same as Plate XXV, four hours after administration. 



I'LATI'-. X.W IN 




Eight hours after administration of bismuth. Stomach stil! 
full and very little bismuth has reached colon. 



1 



I'LATh: WIN 




Sixteen hours after administration. Stomach full. Still 
much bismuth in stomach and very little in large intestine. It 
can readily be seen that if this represents the amount c)t_food 
which passes, starvation must follow. Compare Plates XX\' t-) 
XXIX inclusive with Plates XX to XX1\' inclusive. 



TREATMENT. 337 v 

struction tO' be treated surgically, but also those incomplete 
cases in which the degree of obstruction is so great and so 
persistent that for all intents and purposes they may be 
regarded as complete. In these cases the amount of bis- 
muth which passes through, representing really the same 
amount of food, is negligible and certainly is not sufficient 
to maintain tissue balance, let alone to provide for growth 
as well (Plates XXV to XXIX). Therefore, in deciding 
the issue, the character of the weight chart is of prime im- 
portance. My study of many cases convinces me that all 
operative cases will show a weight curve represented by 
Fig. 50, and that all non-operative cases, charts like Figs. 
52 and 53. The further elucidation of this important 
point is assisted by a careful study of the X-ray's findings, 
the charcoal test, and the degree of constipation. It is 
important to emphasize that the distinction between sur- 
gical and non-surgical cases must be made upon clinical 
•findings alone, and not on the cause of the obstruction, even 
were this always determinable. It is perfectly conceivable 
that simple spasm may be so intense and so persistent as 
to entirely occlude the pyloric orifice, while, on the other 
hand, hypertrophy may occur without causing even as 
much encroachment upon the lumen. In order to facili- 
tate an early distinction the differential table on next page is 

submitted. 

TREATMENT. 

At present this is either surgical or non-surgical. Xo 
preventive methods are known. 

Surgical. — I shall not discuss the surgical treatment 
from the standpoint of technique. This has been ably done 
by Dr. John B. Deaver. The province of the physician, I 
believe, is to determine whether or not operation should be 



338 



PYLORIC OBSTRUCTION. 



Differential Table, 
non-surgical. 
I. Weight curve resembles 



SURGICAL. 

I. Weight curve resembles the 



curve of continued fever with 
slight remissions and elevations. 
At end of week it is stationary or 
but slight loss or gain is recorded. 

2. General strength not mate- 
rially reduced at end of this time. 

3. Bowels constipated, but of 
fair size, and movements contain 
curds or digested milk. 



4. Recovery, of considerable 
quantity of charcoal in anal dis- 
charges, although its passage is 
delayed. 



5. Non-recovery or recovery of 
but little charcoal in the stomach 
washings twenty- four hours later. 

6. X-ray examination confirm- 
atory of charcoal findings and 
character of the constipation. Re- 
veals more or less bismuth in the 
small and large intestines. 



7. Severity of vomiting is 
intermittent and often yields to 
gastric lavage. 

8. Pylorus non-palpable or in- 
termittently so. 

9. Intelligent and individual care 
of the infant at home may delay 
or permanently eliminate the 
necessity for operation even in 
severe cases. 



crisis of a pneumonia. End of a 
week records a loss of 8 to 10 
ounces or more. 

2. General strength fails rap- 
idly. 

3. Constipation absolute or 
nearly so. Milk feces may be 
passed, but only in very small 
amounts. Movement ordinarily 
consists of bile-stained mucus. 

4. Non-recovery of charcoal in 
anal discharges, or very little, and 
this appears first thirty-six to 
forty-eight hours later, and con- 
tinues for many days. 

5. Recovery of considerable 
quantity of charcoal in the stom- 
ach washings twenty- four hours 
or more after administration. 

6. X-ray pictures taken in 
series for a period of twenty-four 
hours show retention of bismuth 
within the stomach, and not any or 
only traces in the small and large 
intestines. Bismuth shadow has a 
"comet-like" appearance. 

7. Constant. Not influenced by 
gastric lavage. 

8. Constantly palpable except 
before emaciation occurs. 

9. Nearly all hospital cases and 
those in which the environmental 
influences are bad should be oper- 
ated upon irrespective of the de- 
gree of obstruction. 



TREATMENT. /^9 

done. This must not be left to the surpfcon .alone, who. as 
a rule, has httle patience with less rapid mctluKls and cer- 
tainly can have had but little experience in handling non- 
surgical cases. It is hoped that the forcj^oinpf discussion 
will materially assist the medical atteuflant to reach a safe 
conclusion. The surgeon must decide the choice of ojiera- 
tion. In all of my cases ix)steri()r gastrojejunostomy was 
performed. The results have been so satisfactory that I 
prefer it. I believe this to be the operation of ])refercnce 
with most surgeons. Divulsion has l)een recommended, but 
it seems uncertain. Simple incision of the pylorus along 
its longitudinal axis through the peritoneum and muscle, 
doTJim to but not through the mucosa, has been practised 
with immediate good results. No sutures are taken in the 
pylorus. The circular fibres are thus severed. The lumen 
of the pyloirus becomes patulous. The abdomen is imme- 
diately closed and the wound in the pylorus is allowed to 
heal by granulation. What the subsequent life of such 
an individual woiuld be, is uncertain. The old scar may cause 
considerable trouble through further contracti(^n, although 
theoretically it should not. This operation was devised by 
Ramstedt and is recommended by E. Peer (Ziirich). A 
case successfully treated in this manner is reported from 
Ko'plik's clinic in the New York Medical Journal. As 
noted below, Dr. Deaver does not recommend this operation. 
What is the subsequent course of cases operated upon 
by gastroenterostomy? This is a matter of pertinent 
interest. Does the pylorus become patulous?- Does the 
artificial opening enlarge and continue to functionate 
properly throughout adult life? Does food leave the stom- 
ach via both the artificial and the natural routes? These 
questions are difficult to determine accurately. I believe 



340 PYLORIC OBSTRUCTION. 

that the cause of the obstruction plays an important part 
as to whether the pylorus subsequently becomes patulous or 
not. Where spasm overshadows the amount of hyper- 
trophy, in all probability food will again pass through the 
pylorus. Where hypertrophy is the main factor, permanent 
occlusion is most likely. In all the cases which I have been 
permitted to study with the X-ray, after operation, the arti- 
ficial opening alone was functionating and the pylorus was 
still impervious. The oldest child thus studied was 3^^ 
years of age. In discussing this point with pediatrists and 
surgeons, it appears that the concensus of opinion is that 
this represents the usual course of events. Further skia- 
graphic and post-mortem studies are necessary to- determine 
this with accuracy. Fig. 49 represents the effect of a suc- 
cessful gastroenterostomy upon the weight curve of a case 
of complete pyloric obstruction. 

Postoperative Treatment. — This undoubtedly should be 
supervised by the pediatrist. Vomiting may persist after 
operation and serious diarrhea may occur. I have also seen 
severe convulsions in a case with continuous bilioius vomit- 
ing. Ultimate recovery resulted. Postoperative vomiting 
may be due to the regurgitation of bile into the stomach or 
it may result from postoperative volvulus of the proximal 
portion of the small intestine used in making the anas- 
tomosis. Convulsions may likewise result from the entrance 
of bile into the stomach and its absorption from the gastric 
mucosa. Therefore gentle stomach washings with warm 
bicarbonate of soda solution may be instituted twelve to 
eighteen hours after operation, and the infant may be sus- 
pended by the shoulders in an upright position. Thus by 
gravity the course of the bile is assisted in taking a normal 
direction. 



TREATMENT. .S U 

Smiall quantities of diliitcd luiinan milk may be j;ivcn 
either throng-h tlic tube inimccbately followinjj: the stomach 
v/ashing or by mouth, usin^: a mc(bc-iiK- (h'nppcr. Twenty- 
four hours after operation rep.ilar feechn^s with the medi- 
cine dropper should be instituted, and as soon as the infant 
is sufficiently strong it should be peniiittcd to suck the 
breast. Where breast milk is unobtainable, feeding should 
be inaugurated with weak animal juices, to be followetl by 
whey, pancreatized formula, or very weak whole-milk dilu- 
tions boiled or modified by Benger's Food or by (lour ball 
and pancreatin. 

Diarrhea may be controlled largely by <liet and by the 
use of eiweissmilch or by a hypodemiic injectifjii of m()r])hin. 

To combat shock immediately after operation, hypoder- 
niioclysis of normal saline solution is valuable, or the water 
may be delivered tO' the tissues by the use of the Murphy 
drip, normal saline solution containing from i to 2 fhii- 
drams of whisky to the pint being employed. 

The utmost finesse of judgment is required in meeting 
the postoperative exigencies which arise. Great care should 
be exercised not to do too much, but to give nature a chance 
to adjust herself to the new conditions. The feeding, espe- 
cially if artificial, should be super\'ised for some months 
following operation, for gastrointestinal upsets may bring 
serious consequences. 

Non-surgical.— This embraces (a) dietetic, (b) me- 
chanical, and (c) medicinal measures. 

Dietetic. — In the beginning "these cases should undoubt- 
edly be kept upon the breast or returned to it if the mam- 
mary gland is still functionating sufficiently. It is my cus- 
tom ahvays to take the mother into my confidence and. 
after explaining to her the nature of the case, to insist that 



342 PYLORIC OBSTRUCTION. 

her full co-operation is essential to a successful result. Her 
nervousness is in a measure overcome and a steady floiw of 
fairly uniform milk is thus assured. If the maternal milk 
has been lost, recourse must be had to a wet-nurse, if this 
be possible. In some communities and under some condi- 
tions the services of these women cannot be obtained. In 
one case I received daily a small coirrplement of milk from 
four different mothers, living in widely separated sections 
of Philadelphia. This was carried to the house, where it 
was mixed together, diluted with water, and fed tO' the 
infant with either a medicine dropper or throrugh a bottle. 
This was continued until a satisfactory wet-nurse was 
secured. The beneficiary of these four, good, unselfish 
women is now a robust boy of over 3 years. Whatever 
method of feeding is adopted, it is important to insist upon 
strict regularity. In my experience short meals lasting two 
to three minutes given every hour are better tolerated than 
when the long-interval feeding of large meals is adopted. 
Vomiting is sometimes lessened by feeding the breast milk 
through a medicine dropper, or it may be slowly injected 
by means of a small syringe before removing the catheter 
directly following a stomach washing. Vomiting is some- 
times remarkably controlled by this maneuver when it con- 
stantly follows feeding by sucking either the bottle or the 
breast. After feeding, the infant should lie upon its right 
side to favor the rapid emptying of the stomach. 

Where the breast is not available we must depend upon 
artificial feeding. Whey may be tried for a while. If it 
agrees, very small amounts of whole or of skimmed milk 
or even cream may be added, after carefully heating the 
whey in order to prevent coagulation of the added milk or 
cream (Chapter III, page 120). I have seen some cases do 



1 



TREATMENT. (^^^ 

well on a highly diluted condensed milk. This contains 
very little protein and fat and considerable sugar, which 
readily furnishes the heat which these infants require so 
badly. If the stomach contents l:>e sour and highly acid, any 
of these substances or even the milk mixtures, to which 
reference will be made presently, may be largely diluterl 
with lime-water up to 50 per cent, of the entire fliluent 
employed. It may assist in controlling vomiting. Where 
ordinary milk formulas are employed, large doses of sodium 
citrate (see later) are useful to prevent coagulation of the 
milk in the stomach. 

I believe that simple dilutions of whole or of skimmed 
milk to be as useful as any of the more elaborate modifica- 
tions. Especially is this true if the mixture l)e lx>ilcd or if 
Benger's Food or flour ball and pancreatin be employed t(j 
modify the curd and to assist in the digestion of the fat. 
High' dilutions are at first employed, i to 2 ounces in 20 of 
diluent. This should either be barley-water or oatmeal- 
water, or plain boiled water or a mixture of equal parts of 
the cereal-water and boiled water. The last is usually to 
be preferred. Lime-water may be substituted f<>r any of 
these. To the formula, modified either by Benger's Food 
or by flour ball, sodium citrate may in addition be added. 
Small doses of the formula are given often. Gradually the 
strength of the mixture is increased. 

Additional carbohydrate is furnished by either cane- 
sugar or by some preparation of maltose, as Mead-Johnson's 
Dextri-Maltose or Loeilund's Food Maltose. In these cases 
I prefer the malt-sugars, on account of their rapid absorb- 
ability. They maintain body temperature and. I believe, 
cause a more rapid gain in weight. Some cases kept up< »n 
the breast showed improvement as far as the nutrition and 



344 PYLORIC OBSTRUCTION. 

temperature were concerned by the addition tO' the diet of a 
simple 5 per cent, solution of Dextri-Maltose. 

M^hy it is so I cannot explain, but I have noticed the 
clinical fact that many cases which are doing indHferently 
zvell upon the breast alone, gaining an ounce or two a week 
or just holding their own, take a spurt, if given a simple 
formula prepared as just described. The bottle is given at 
every other feeding", and then gradually the baby is trans- 
ferred to artificial food entirely. Whether this be merely 
a coincidence, or whether it depends upon the food, thus 
furnishing a clue as to the ultimate cause of the spasm, ov 
hypertrophy v/hich may be causing the obstruction, is diffi- 
cult to determine, but as a practical therapeutic fact it is 
well worth remembering. I have only seen this occur after 
the use of milk treated in the following manner, viz., highly 
diluted, boiled, and modified either by Benger's Food or by 
flour ball and pancreatin. 

- Animal broths are at times sustaining, especially in 
surgical cases' just preceding operation. They may be 
given by mouth or per rectum. 

Enemas of peptonized milk are useful for the same pur- 
pose. Too great dependence should not be placed upon 
them. Their bulk should always be small, and not more 
than 2 should be administered during each twenty-four 
hours. 

Mechanical Measures.- — The one single remedy which 
approaches specific proportions in the management of non- 
surgical cases is gastric lavage. If nothing else be at hand, 
plain warm water will do. Normal salt solution is better, 
however, and better still is a solution of i dram of bicar- 
bonate of soda to the pint of water. The temperature 
should be ioo° F. The washing should be continued until 



TREATMEiNT. '^-345 

the fluid comes away clear. Tlie daily nimibcr of washings 
varies with the severity of the vomiting — not less than i 
and preferably 2 or 3. If possible the washings should 
immediately follow a vomiting six?ll, and immediately after 
this food should be administered. (See page 363.) 

In some instances the fluid enters readily enough, 
but the contractions of the stomach are so forceful that the 
contents are shot out alongside of the tube. This accom- 
plishes as much as if the fluid were siphoned away. There 
is some danger, slight however, that fluid or curds may Ijc 
aspirated intO' the larynx or bronchi and cause immediate 
suffocation or, later, bronchopneumonia. In order to avoid 
this the catheter should be immediately withdrawn during 
the gush of fluid and the infant inverted. As the case im- 
proves the number of washings is gradually decreased and 
finally omitted. 

It is important to keep the rectal temperature between 
99° and 100° F. With this in view the baby should be 
properly protected by clothing and the judicious application 
of external heat. 

Medicinal. — Drugs are only adjuvants. I only employ 
them for a definite reason. Of the bromids I prefer the 
strontium or the sodium salt. The former is given in the 
shape of Paraf Javal's solution marketed by Chapoteaut. 
Each fluidram contains y'jA grains, and from 10 to 15 
minims are administered in a little water before every 
feeding or before alternate feedings. From i to 2 grains of 
the salt dissolved in plain water may be thus employed. I 
have also used sodium bromid. It appears, however, to be 
more irritating in the stomach and more readily produces a 
bromid rash, which in itself may be an element of danger 
(Complications, page 334). 



346 PYLORIC OBSTRUCTION. 

If the bromid has no effect upon the vomiting, I have 
made use of an occasional dose of morphin sulphate 
gr. ^/soo to gr. ^ /300 by hypodermic injection. This has in 
some cases worked splendidly and without ill-effect. Where 
the appetite has failed i to 2 drops of the tincture of nux 
vomica have been of some use. 

Impressed by the good effect of liquid paraffin in the 
treatment of constipation, I believe that this substance 
should be given a trial in the milder cases of incomplete 
obstruction. I have employed it in but 2 cases and, I be- 
lieve, with some good effect in allaying pyloric spasm and 
in asisting the onward movement of the aliment. About J^ 
to I dram should be given three times a day. Any of the 
good oils, foreign or domestic, tO' be found on the market 
will answer this purpose. 

Sodium citrate is a valuable agent when used in con- 
junction with proper feeding. Its purpose is to keep the 
milk liquid in the stomach, so as to assist in its easy passage 
through the pylorus. To infants on the breast I have given 
as much as 10 or 15 grains five or six times a day, before 
feeds. I believe however that ordinarily from 2 to 5 grains 
are sufficient. I find no ill-effects from its use. It should 
enter into the composition of every milk fo'rmula in those 
cases artificially fed. The dose is from i to 3 grains for 
every ounce of milk and cream in the bottle. 

Codliver oil, especially in cold weather, should be used 
freely daily or bidaily in the form of inunctions. 

SURGICAL TREATMENT OF INFANTILE 

PYLORIC OBSTRUCTION. 

By John B. Deaver, M.D. 

When surgical treatment has been decided upon it be- 
comes necessary to select that form of operation which will 



I 



SURGICAL Tkl-ATMENT. I^J^J 

accomplish tlie best result. In cloin^ this we must be guided 
not only by the chaiif^-e in the stomach, hut also the tender 
age of the patient. 

The operations that have l>een done in the attempt to 
correct this condition are pylorodosis, pyloro|)lasty, ^^'ustro- 
jejunostomy, and pylorectomy. Pylorectomy has been done 
but once, so far as I know, with fatal result. Gastro- 
pyloroduodenostomy has been done unsuccessfully in i case. 
Pylorodosis is an operation which may l^e quickly per- 
formed, requires but little exposure of the viscera, and is 
theoretically safe, but practically does not give the Ijcst 
results. In a fev^ instances the pylonis has been split longi- 
tudinally down to but not including the mucosa (Ramstedtj, 
instead of stretching, and death has frequently resulted 
from shock or from peritonitis. In my early experience 
with this disease I performed a number of these operations 
with, as a rule, unsatisfacton^ results; therefore I have dis- 
carded this method entirely. In i of my cases I had sub- 
sequently to make a posterior gastroenterostomy. 

Dufour and Fredet have collected 36 operations by the 
Ramstedt method, with 9 deaths. One patient who re- 
covered required gastroenterostomy later. Personally, I 
would strongly advise against this operation. 

Posterior gastrojejunostomy is the only operation I now 
perform, and the results warrant, I am sure, the statement 
that it is the only operation to be considered. The tech- 
nique of the operation is exactly the technique of posterior 
gastrojejunostomy in the adult, the only difference being 
that it is preferable to use smaller anastomosis clamps on 
account of the jejunum being so much smaller in the child 
than in the adult. The essential points to be considered in 
this operation in the child are, first, rapidity; second, that 



348 PYLORIC OBSTRUCTION. 

the anastomo'sisi be made as close to^ the duodenojejunal 
junction as possible, thereby preventing regurgitant vomit- 
ing; third, that 3 rows of sutures be used, the outermost of 
linen and the 2 innermost of chromic catgut. The linen 
suture should only include the serous and the muscular 
coats and must be introduced v/ith great care on account 
of the thinness of the wall of the jejunum. Before 
introducing the second row of sutures divide the serous and 
muscular coats of the stomach and small bowel between 
one-fourth and one-eighth of an inch from the line of the 
apposed viscera. This row of sutures is then carried 
through the divided coats. The third row of sutures is 
passed after the viscera are opened, and includes all the 
coats. 

AFTER-TREATMENT. 

The after-treatment consists in keeping the child in a 
sitting position in bed by a sling passed beneath the buttocks 
in the manner in which all cases of posterior gastroenteros- 
tomy are handled for a few days immediately after the 
operation. Nothing is given by mouth until after the 
passage of gas by bowel, which, in the majority of in- 
stances, occurs within twenty-four hours. Then, if the 
stomach be retentive, water, to. be followed by albumdn- 
water, broth, and similar substances are allowed. If the 
condition continues favorable, diluted milk foirmula, pre- 
digested or not, may be given. As the child continues to 
improve the milk formula is strengthened and a larger 
quantity given. 

If the stomach is not retentive, or if there is vomiting 
irrespective of taking nourishment, the stomach isi tO' be 
washed out. In fact, this is the only thing that accom- 
plishes any good. In my experience, to give medicines, as 



AFTER-TREATMENT. (,,..^49 

bisnuith, cocaine, oxalate of cerium, aiul such other agents 
believed to be of some use iu controUinp nausea, is al)so- 
lutely of no use in cases of this character. 

It not infrequently happens that a few hours after 
operation the child will vomit some old blood which emits 
a disagreeable odor, and, if so, lavage should be immediately 
practised. 

It is my practice to give these children enteroclysis for 
two or three days. At the end of the fourth day the bowels 
are opened by enema. Rarely it is necessary to give an 
aperient or purgative. If the condition is at all favorable 
for operation these cases should get well with little or no 
anxiety on the part of the surgeon. ProcTastination, in 
surgical cases, in the hope that the child will be Ix^tter with- 
out operation, until the condition becomes alamiing, causes 
operation to become a matter of much moment, and the con- 
sequent responsibility of the surgeon to ]ye correspondingly 
greater. 

The incision is made through the middle of the right 
rectus muscle. In closing, the peritoneum is apposed by a 
continuous iodin-catgut suture. Two or more interrupted 
sillavorm-gut sutures are passed through all tissues, down 
to the peritoneum. The sheath of the rectus is made to 
overlap and is fixed by a continuous iodin suture. The skin 
is closed with silkworm gut or horsehair. The interrupted 
stitches should not be removed for nine or ten days, the 
child being strapped with adhesive plaster. The plaster ex- 
tends completely around the abdomen. When the stitches 
are remo^-ed too early, the edges of the wound may separate, 
causing ventral hernia. I have met this accident, but have 
corrected it by immediate replacing. 



CHAPTER XIII, 
SPECIAL TOPICS. 



DESCRIPTION OF APPARATUS. 

Should his practice bring him into frequent contact 
with children, the physician should have the apparatus 
pictured in Fig. 56 always at hand, in good condition and 
ready for use. 

A consists of a small glass funnel ( i ) holding not less 
than 2 ounces and preferably 3. The funnel is attached 
to a piece of rubber tubing (2) about 6 to 8 inches in 
length. To this is connected a piece of glass tubing (3) 
2 to 3 inches in length, and to this is finally attached a soft, 
red-rubber catheter (4), No. 22 to No. 26 French. An 
extra eyelet is cut into the catheter about ^ inch from 
the end. 

B consists of a small, rubber, hand-bulb syringe (5) 
with a hard-rubber tip (6). In the figure it is con- 
nected with a soft, red-rubber catheter, No. 22 to No. 26 
French (7). 

C is a glass syringe which may be employed instead of 
the hard-rubber syringe, and is especially useful in nasal 
feeding. 

D is a rubber fountain syringe holding 2 quarts (8). 
To the hard-rubber tip at the end is attached a No-. 22 to 
No. 26 soft, red-rubber catheter (9). It may be remarked 
that it is not necessary for the physician to possess more 
than one catheter, as it can be readily removed and be 
attached to that apparatus being employed at the time. 
(350) 



DESCRIPTION OF APPARATUS. 



^51 



E is a sharp-pointed, holloiif, steel needle do) a>ii- 
nected to a piece of rubber tubing (ii). If the catheter 
(4) be removed in A and this rubber tubing with the needle 
be connected to the o^lass tubinf,'- f 3 ), a convenient apparatus 
for hypodermoclysis or for intravenrnw iiiicction Thy 
gravity) is secured. 




Fig. 56. — A, glass funnel (i), rubber tubing (2j, glass connecting 
tubing (3), catheter No. 22 to No, 26 French (4). B, small, rubber, 
hand-bulb syringe (5), small, hard-rubber connecting tip (6), catheter 
No. 22 tQ No. 26 French (7). C, glass syringe. D, fountain syringe 
(8), catheter No. 22 to No. 26 French (9). E, hollow needle (10), 
rubber tubing (11). F, smallest caliber catheter. 

F is the very smallest red-rubber catheter obtainable, 
employed in nasal feeding. 

It will thus be seen that with this apparatus tlie phy- 
sician is equipped to perfomi such useful maneuvers as 
stomach washing; feeding by stomach-tube; nasal feeding; 
the administration of medicine via the tube, if the patient 
cannot swallow; bowel irrigation; the giving of a nutrient 



352 SPECIAL TOPICS. 

or medicinal enema (high or low), and to administer saline 
or other medicinal solutions by hypodermoclysis or intra- 
venously. 

STOMACH WASHING (LAVAGE). 

Solutions Employed. — Plain faucet- water will do. Sterile 
water is better. Normal saline soluton is still better. 
A solution containing i dram of sodiumi chlorid and 
I dram of bicarbonate of soda toi the pint is best for 
routine purposes. For special occasions tannic acid ( i per 
cent, to 2 per cent. ) , potassium^ permanganate i : 8000, silver 
nitrate i : 10,000, may be of service in the presence of 
bleeding, morphin or other alkaloidal poisoning, or gastric 
ulceration or catarrh. For the control of the bleeding in 
gastric ulcer of adults Rodman recommends filling the 
stomach with hot water, the temperature being as high as 
is endurable by the patient. For ordinary purposes the 
temperature of the solution should be that of the body — 
98° to 100° F. The quantity employed depends upon the 
indication for which the washing is done. The washing is 
continued until the indication is overcome or mitigated. 
Ordinarily frotm i to 2 quarts are employed. As a rule, 
but I washing a day is allowed, although if much benefit 
follow, as in some cases of pyloric obstructiou, it may be 
repeated twO', three, and even four times within twenty- 
four hours. 

Technique. — Apparatus A is employed. The patient is 
placed flat upon the back and wrapped in a small sheet or 
blanlcet in order to secure the arms. The head is steadied 
in the median line by an assistant. The catheter is made 
moist with the solution tO' be used. The tip of the catheter 
is passed along the dorsum of the tongue until it touches 



STOMACH WASHING (LAVAGE). I ^^ 

the i>ostpharyngeal wall. Pressure is continued and the 
catheter will oii<lc directly into the esopha^ais. ihnnigh 
which it enters the stomach. Tiie funnel is then held in a 
vertical posiiion to allow g-as to l)e expelled. This drx-s iK>t 
always occur, but some of the gastric contents commonly 
appear at the g-lass 0)nnectin2;--tul>in<r or shoot into and 
sometimes out of the funnel. The fluid is now poured into 
the funnel and, unless the infant strug.c^les, it will gradually 
enter the stomach. As it disappears from the funnel the 
latter is again filled. Just as the fluid is about to disappear 
for the second or the third time, depending u\h>u the age of 
the baby, the funnel is depressed l)elow the level of the 
patient and the gastric contents are siphoned into a recep- 
tacle. This maneuver is again repeated. This refilling and 
siphoning are continued until the flui<l returns clear 
(Figs. 57 and 58). 

If the patient struggles, and in older children, the task 
becomes less easy. The patient cries and compresses its 
abdominal muscles, and the fluid will not enter the stomach, 
but moves up and down in the apparatus. If the indication 
for the washing is urgent, the funnel must be patiently held 
in the vertical position imtil the infant relaxes or in some 
cases the operation must be abandoned. The straining may 
be so great as to cause the tube to be forcibly exp)elled 
through the mouth. Under these circumstances the tube is 
to be replaced two or three times before the attempt is 
abandoned. Straining may cause the fluid to gush out oi 
the infant's mouth. This does not interfere with the accom- 
plishment of a successful result. The stomach is cleansed 
W'hether the fluid is returned through the apparatus or via 
the infant's mouth. In yet other instances the catheter 
may become blocked by tough mucus or curds, or both. 



23 



354 



SPECIAL TOPICS. 



Under these circumstances the tube may be withdrawn and 
an extra eyelet may be cut into its side, or the apparatus 
may be filled with the solution tO' be employed before pass- 




Fig. 57.— Stomach washing. The funnel is held erect to allow 
the fluid to enter the stomach. 



ing the catheter. The tubing is pinched until the catheter 
enters the stomach. When release of pressure is made the 
fluid will flow because, the apparatus being filled, in view of 



STOMACH \V.\SIII.\<. (L.\\'.\(.I- 



/ .. 355 



the law of llic imiK'nclrahility of matter (two tiling cannot 
occupy the same ])lacc' at the same time), no curd nor 
mucus can enter the catheter. 'I'hc entrance of the tUiid 




Pig 58.— Stomach washing. The futincl is depressed to filler 
away the stomach contents, which flow into tlu- l-ul. 

itself into the stomach will cause the cunl <t niiRii> i -'c 
broken up, and thus also the probability of the one or the 
other blocking the apparatus is materially lessened. 



356 SPECIAL TOPICS. 

Enemata. — Apparatus B is employed. An enema may 
be either high or low. A low enema is given below the 
internal sphincter, its purpose being toi empty the rectum. 
A high enema is given above the internal sphincter. In 
giving the low enema the small, rubber, hand-bulb syringe 
is employed. In giving the high enema this apparatus with 
the catheter attached is used. The purpose of the high 
enema may be to cleanse the rectum and sigmoid or tO' place 
medicine or nutriment intO' the lower bowel. For cleansing 
purposes plain simple water or saline solution, or a mixture 
of soap and water with the addition of a small amount of 
turpentine and glycerin, may be employed. A high enema 
should always be preceded by a low enema, thus avoiding 
blocking oif the catheter by feces. The catheter is anointed 
and passed within the bowel for a distance of from 4 toi 6 
or 8 inches, care being taken that the catheter doies not 
curl upon itself. After being properly placed the solution 
toi be employed is injected into the bowel through the 
catheter by means of the small, rubber, rectal syringe, or by 
means of gravity, use being made of a funnel or a fountain 
syringe. 

A high enenia may also be introduced purely by gravity 
without the use of the catheter. The patient is simply 
placed in the knee-chest position and the tip of the fountain 
syringe in apparatus D is anointed and gently inserted into 
the rectum. The bag containing the fluid is held or hung 
about 2 or 3 feet above the patient, and the fluid is allowed 
to gently enter the intestinal canal by the practice of inter- 
mittent compression upon the rubber tube. Not more than 
5 or 6 ounces of fluid should be permitted to enter the bowel 
(Fig. 61). Within a few minutes the patient will expel 
the enema and a large amount of feces. 



COLONIC IRRIGATION. 



357 



COLONIC IRRIGATION. 
Indications. — Wlien properly employed, colonic washing 
constitutes a useful therapeutic asset. It is, however, not 




Fig. 59. — Colonic irrigation with the catheter. The tip is intro- 
duced and the buttocks are seen to be pressed together (so that no 
water can escape) in order to balloon the rectum. 



without danger, especially when continued without reason 
OA^er a long- period of time. A distinct indication must exist 



358 



SPECIAL TOPICS. 



and the washings must cease as soon as this is overcome, or 
it appears clear that they will accomplish no good. In 




Fig. 60 — Colonic irrigation with catheter. The catheter has been 
pushed in for its entire length and the water is seen escaping along- 
side of it and over the buttocks. 



chronic constipation a single irrigation is useful to unload 
a crowded bowel. In this condition it should not be em- 
ployed more than once within a fortnight. It is also indi- 



COLONIC IRRIGATION. 



359 



cated in eclam])sia, suninier complaint (intoxication), intes- 
tinal parasites, intestinal putrefaction, dyspeptic diarrhea, 




Fig. 6i. — Giving a colonic irrigation or a high enema without in- 
serting the catheter. The infant is placed in the knee-chest posture 
and the hard-rubber tip of the syringe is simply placed within the anus 
and the water flows by gravity. 



and in dysentery. It is one of the most powerful means of 
reducing high temperature. 



360 SPECIAL TOPICS. 

Technique. — Plain sterile water, normal salt solution, or 
medicated fluids may be employed. In intestinal ulceration 
a weak solution of silver nitrate i : 10,000 or a i or a 2 per 
cent, solution of tannic acid may prove beneficial. The tem- 
perature O'f the fluid varies as toi the indications to be met. In 
all instances, except in fever, it should be between 98° and 
100° F. If the patient has fever, cold water or, better, 
gradually cooled water, or even ice-water, is valuable. 

Apparatus D is employed. The irrigation is preceded 
by a low enema. The child is placed on its left side and 
under its buttocks is arranged a suitable piece of rubber or 
a small Kelly pad, which drains the fluid intoi a bucket. 
The catheter is oiled. The stop-cock is released and the 
flow of fluid expels all air from the catheter. The flow is 
now shut off and the tip of the catheter inserted just beyond 
the internal sphincter. The fluid is again allowed tOi flow 
and the buttocks closely pressed together without compres- 
sing the catheter (Fig. 59). No fluid can escape and the 
lower bowel is ballooned. After a minute or twoi the 
catheter is gently pushed in for its entire length. As the 
colon fills, the belly is gently massaged. The fluid escapes 
in spurts from the anus along the sides of the catheter 
(Fig. 60). The irrigation is continued until the fluid 
returns clear. 

The irrigation may be accomplished without the use of 
the catheter, as in giving a high enema, the child being 
placed in the knee-chest posture (Fig. 61) and the refilling 
and the emptying of the bowel being continued until it is 
cleansed. At intervals the child may be placed upon its 
back with its buttocks elevated while the abdomen is 
massaged upward along the left side across and down the 
right. This insures the fluid reaching the ascending colon. 



NASAL FEEDING. \ ^ 361- 

Accidents. — In experienced hands nothing more than an 
interference with the easy flow of the fluid due to the bend- 
ing- of the catheter upon itself occurs. As the physician 
pushes the instrument into the bowel the tip of the catheter 
reappears again at the anus. This may best be avoided by 
thoroughly ballooning the lower gut, or by passing the 
index-fmger into the rectum and thus guiding the tip of the 
catheter past any obstruction. If the catheter becomes ob- 
structed from any cause, this fact may be determined by 
disconnecting it from the apparatus temporarily, when no 
fluid will flow through it from the bowel. There is some 
slight danger of rupturing an ulcerated bowel if the rubber 
bag be elevated toO' high- above the child. 

NASAL FEEDING. 

Indications. — Unconsciousness. If the child for any 
other reason cannot swallow, as in inflammatory and infec- 
tious conditions of the mouth and throat and after certain 
operative measures upon these parts, and in cases of tetanus. 

Technique. — The infant's hands and arms are secured 
by a towel wrapped around its body. The head is steadied 
in the median line. Apparati F and C are employed. The 
calibre of the catheter must be the smallest obtainable. The 
catheter is anointed with oil. It is passed toward the 
posterior nares, along the floor of the nose. The index- 
finger of the free hand is passed into the fauces to guide the 
tip into the esophagus, otherwise, striking the prominence 
of a cer\acal vertebra, it may become impinged here and 
the bulk of the tube accumulate in the throat, or the tip may 
come out of the mouth. After the tip has entered the stom- 
ach, as is evidenced by the appearance of gastric contents 
at the outlet of the tube projecting from the nose, the food. 



362 



SPECIAL TOPICS. 



previously warmed, may be slowly injected by means of the 
glass S3^ringe (C). Instead of using the syringe the food 




Fig;. 62. — Nasal feeding. 



may be permitted to slowly gravitate by connecting a small 
glass funnel (A, i) with the projecting end of the catheter 
and into this the food is emptied. 



FEEDING BY STOMACH-TUBE (GAVAGE). . 363 

Where necessary the stomach may be washed out 
tlironoh the nose before the food is allowed to enter, and 
medicine may also be administered in this fashion. The 
manenver of nasal feeding" is usually easily accomplished, 
and without inconvenience to the infant. 

FEEDING BY STOMACH-TUBE (GAVAGE). 

Indications. — When the patient will not or can not 
swallow. This may be due to inflammatory conditions of 
the throat or mouth, to paralytic phenomena, as after 
diphtheria or in cases of ascending paralysis, or in tetanus. 
Inability to swallo-w is a part of the clinical picture of coma, 
as seen in convulsions, meningitis, infantile paralysis, after 
head trauma, and during nephritis. Gavage is a valuable 
adjunct in some cases of forced feeding or in anorexia, or in 
cases of persistent vomiting associated with acute intestinal 
intoxication. Food given in this manner is often retained 
when it would be vomited if taken in the ordinary way. 
To the careful clinical observer gavage will suggest itself in 
many other conditions, not necessary to be enumerated. It 
shonld be discontinued the moment the necessity for it ceases 
to exist. 

Technique. — The same apparatus (A) is employed as 
in stomach w^ashing, and the same method of introducing 
the tube is followed. The food, adapted to the needs of the 
individual case, but always liquid and previously warmed, 
is allowed to slowly enter the stomach by the attendant 
making regular but intermittent compression upon the tube. 
On the other hand, one may dispense with the funnel and 
the aliment may be slowly injected through the catheter 
by means of a glass or other syringe, as in nasal feeding. 
During withdrawal the tube must be compressed and re- 



364 SPECIAL TOPICS. 

moved with one swift stroke, between gags. Otherwise 
the gastric contents may be shot out around, with and after 
the tube. 

FEEDING BY BOWEL. 

Nutrient Enemata. — The purpose of this method of 
feeding is toi sustain Hfe over critical periods of acute food 
intolerance or anorexia, and to reinforce mouth feeding 
when the stomach is non-retentive. It may also^ be employed 
during coma from any cause. While it should be tried as 
a dernier ressort, in my opinion it rarely renders signal 
service in saving life. It may also' be employed after opera- 
tions upon the stomach or upon the other organs of the 
upper abdomen. It cannot be depended upon as the sole 
source of introducing nourishment for any great period oif 
time. 

Technique. — The lower bowel should previously be 
emptied by a suppository or preferabh^ by a cleansing high 
enema of simple saline solution. After this the patient 
should rest at least one-half hour in order to permit any 
rectal irritation to pass away. Apparatus B is employed. 
The rubber catheter is well anointed with oil and introduced 
into the bowel, for a distance of from 4 or 5 inches. This 
is accomplished with a variable degree of ease in different 
individuals. The infant is placed on its left side and the 
buttocks are slightly elevated. The enema heated to 100° 
F. is slowly injected by means of the soft-rubber, hand-bulb 
syringe or by means of a glass syringe, or it is allowed to 
flow in by gravity, by connecting apparatus A at the glass 
tubing (3) to the free end of the catheter. From ten to 
fifteen minutes should be consumed in getting the fluid into 
the bowel, whatever method be employed. When all has 



FEEDING DURING INFECTIOUS DISEASES. , 365 

entered, the catheter is pinched and swiftly withdrawn. 
The infant is permitted to he on its left side with its but- 
tocks elevated, or it is placed for a few moments in the 
knee-chest posture while the colon is massaged upward on 
the left side, across, and down the right. The bulk of the 
enema should never exceed 4 to 5 ounces in a child and in 
an infant never moire than i to 2 ounces. Not more than 2 
nutrient enemata should be given within twenty-four hours, 
and they should be at least twelve hours apart. Any 
attempt to increase the bulk or the frequency of administra- 
tion will defeat the puq>ose for which they are given, for 
the rectum speedily becomes irritable and expulsion occurs. 
Composition. — Various formulae have been given. All 
are perhaps good. None appear to me tO' possess any 
special advantage. The following is offered as being suit- 
able in most instances : — 

One egg 

4 oz. of completely pancreatized milk (at least 30 minutes). 

I oz. of water. 

Deodorized tincture of opium, i to 5 drops. 

Ex. of pancreatin, 10 grains. 

Sodium bicarbonate, 10 grains. 

This may be given in whole or in part. If desired, from 
10 to 60 minims of whisky may be added. 

FEEDING DURING THE ACUTE INFECTIOUS 
DISEASES. 

The burden of an infectious process is shared by all 
the vital organs. From this depression of function the 
alimentary canal does not escape. Hence the tolerance for 
food, i.e., the power for digestion and for assimilation, is 
variously diminished, depending upon the resistance of the 
individual and upon the severity, character, and duration 



366 SPECIAL TOPICS. 

of the infectious disease. This diminished digestive power 
is commonly seen when, during the course of an acute in- 
fection, the bowel movements, which previously were nor- 
mal, now show the evidences of dyspepsia, curds, mucus, 
greenish discoloration. So much so is this the case that 
not infrequently the mistake is made of overlooking the in- 
fection, which may be more or less obscure, and of regard- 
ing the case as purely one of food intolerance or of alimen- 
tary disturbance. I have seen this error made repeatedly, 
for instance, with reference to^ acute otitis media. An 
infant falls ill with fever and the bowels become disturbed. 
The patient is treated with reference to these until a dis- 
charge appears at the ear, or a specialist having been called, 
or the doctor himself becoming suspicious from, for in- 
stance, the high leucocyte count, or from a general knowl- 
edge that inflamed ears often occur in infants without pain 
and with fever as their sole symptom, the error is dis- 
covered before rupture occurs as the result of a careful ear 
examination. In one instance this error almost led to a 
fatal issue, as an intense mastoid infection, requiring opera- 
tion, occurred. The child had been ill a week before the 
ear infection was detected. 

The character of the infection, i.e., the nature of the 
toxin, has a very important determinating influence upon 
the degree of severity of the food intolerance. Thus the 
toxin of pneumonia seems very potent in this respect, while, 
on the other hand, those of the acute exanthemata, scarlet 
fever, measles and varicella, and of diphtheria seem> to 
exert scarcely any serious effect upon the digestion. In- 
fluenza, on the other hand, is very depressing. With the 
exception perhaps of scarlet fever, a speedy return may be 
made to the normal amounts of the food to which the in- 



FEEDING DURING INFECTIOUS DISEASES. 367 

dividual has been accustomed during" health. Even in this 
exception we must be cautious, not because of the reduction 
in food to<lerance per sc, but because the scarlatinal toxin is 
especially irritating to the renal tissue. Nephritis commonly 
results, and it is with a view of preventing this complication 
that special measures must be pursued. 

The damaging effects of the pneumotoxin upon food 
tolerance and the best means of overcoming it are of suffi- 
cient importance to require detailed comment. The pneu- 
niotoxin probably acts in two ways. First, simply as most 
toxins act — by diminishing the functional activity of the 
glands of digestion and the assimilative apparatus, and, 
second, by directly paralyzing, in susceptible individuals, 
the unstriped muscle-fibre of the intestines, because tym- 
panites is a common complication of this disease. It should 
also be emphasized that it is a highly dangerous one, and 
one of the most fatal. From the outset, therefore, it must 
be borne in mind, and every means should be employed to 
prevent its incidence or tO' mitigate its severity, or to re- 
move it entirely. The last ofttimes is a baffling and 
impossible task. 

The author recommends that in nurslings mother's milk 
should if possible be the sole source of nutriment. If the 
infant be bottle-fed, milk in all forms should be excluded, 
if possible, as well as sugars and starches. If it be impos- 
sible to omit milk entirely, it should be given skimmed and 
highly diluted and pancreatized, or modified by the addi- 
tion of flour ball and pancreatin, or of Benger's Food. 
Reliance should be placed mainly upon animal juices and 
broths and upon protein foods. The last, in sucklings, 
should consist of egg-albumin water, in addition to* the 
animal juices. In older children skinned mashed peas and 



368 SPECIAL TOPICS. 

Lima beans and eggs boiled or coddled two minutes should 
be employed. Breadcrumbs made of dry stale bread may 
be rubbed up with the Qgg. In addition to the milk prepara- 
tions above indicated, Finkelstein's eiweissmilch or plain 
buttermilk, or one-third milk and two^thirds water, boiled 
with Larosan, may be employed. Should constipation 
occur as the result of this feeding, rectal enemata, sup- 
positories, or tonic laxatives, as the aromatic fluidextract of 
cascara sagrada in J^-dram doses, should be used. Dras- 
tic purgatives, as calomel and castor oil, often cause the 
tympanites to become worse by further relaxing the intes- 
tinal muscularis. The lack of sugar may be met by the use 
of saccharin. Water in abundance should be given to 
attenuate the pneumotoxin. 

Aside from the dietary measures advocated, the good 
effect of the milk of asafetida in a dose of J^ or i dram 
by mouth, or of 2 ounces by enema alone, or combined with 
10 grains of charcoal, should not be forgotten. While 
serving as interne on my service at the Mt. Sinai Hospital, 
Dr. M. I. Moss devised the following medicinal enema, 
which was frequently employed with excellent effect: — 

One-half ounce of an emulsion made with acacia con- 
tains 5 minims of the spirits of turpentine, 2 fluidrams of 
the emulsion of asafetida, and i dram each of powdered 
charcoal and bismuth subcarbonate. 

The application of cold compresses, of hot turpentine 
stupes, or of the warmed spice poultice (a small oblong bag 
is made of muslin and partly filled with allspice and securely 
sewed on all four sides) tO' the abdomen, may often 
assist in reducing the tympanites. I have seen very little 
effect from the hypodermic injection of eserin salicylate or 
of atropin sulphate. Digestants, as the extract of pan- 



FEEDING DURING INTUBATION. / 369 

creatin and of taka-diastase, 2 gr. each, administered four 
times daily, may be of some assistance. The permanent 
insertion of a No. 22 to No. 26 French soft-rubber catheter 
hig-h into the bowel may facilitate the passage of the gas. 

FEEDING IN NEPHRITIS. 

After following many cases of acute and subacute 
nephritis to recovery I am convinced that the investigations 
of Martin H. Fischer with reference to sodium chlorid are 
not only correct, but that they provide invaluable data in 
the treatment of this disease. I therefore advocate the 
addition of salt to the diet of all nephritics in plentiful 
quantities, and administer it as well per rectum, hypoder- 
mically and intravenously. Aside from this there is no 
need for further comment except to advise the administra- 
tion of wholesome, well-cooked, and easily digested foods 
in small quantities. 

FEEDING DURING INTUBATION. 

The blandest of food should be given in order not to 
induce cO'Ughing, as this may cause the tube to be expelled. 
Milk and milk foods are best. Infants at the breast very 
often can continue this method of feeding, provided the 
milk be pumped and fed with a spoon or dropper. If swal- 
lowing cannot be accomplished the food may be given 
through a stomach-tube or, better yet, by nasal feeding. The 
question of feeding during intubation is largely a problem of 
position. Some patients have trouble when attempting to 
swallow liquids. This may be overcome by holding the 
baby so that its head is lower than its trunk. This is 
known as the Casselberry position. 

24 



370 SPECIAL TOPICS. 

HYPODERMOCLYSIS. 

This means the injection of fluids, usually normal 
saline solution, under the skin for the purpose of ab- 
sorption. 

Indications. — It is useful in all conditions associated 
with a great loss of the body fluid and in acute or chronic 
toxic states. Thus it finds its chief indication in cholera 
infantum (intoxication), hemorrhage, certain types of 
infantile atrophy, chronic diarrhea, acute infectious diseases 
associated with suppression of the urine, asphyxia, acute 
and chronic nephritis, uremia, certain anemias, and some- 
times after operation. 

Physiologic Action.— The effect produced depends 
largely upon the extra amount of water w^hich enters the 
system and, according tO' the researches of Martin H. 
Fischer, the sodium chlorid has a direct specific action in 
controlling the solution of the colloidal substances of which 
the kidney is composed. This is a direct contradiction to the 
commonly accepted opinion that common salt is largely con- 
traindicated in the nephritides. The imbibed water in- 
creases the normal fluidsi of the body and bathes the dried 
and parched tissues. The volume of the blood is increased 
and the arterial pressure augmented. The force and the 
volume of the cardiac beat is strengthened. The water 
dilutes the toxins and minimizes their deleterious action 
upon the internal viscera. The chlorid of sodium inhibits 
the action of acids in causing the solution of the normal 
tissue colloids. The increased diuresis causes the more 
rapid elimination of these toxins. 

Technique. — Apparatus A is employed except that the 
catheter (4) is replaced by connecting apparatus E to the 
glass tubing (3) of A. The skin of the abdomen is 



HYPODERMOCLYSIS. 



-371 



the preferable site for injection. A ])oint is sterilizecl by 
the apphcation of a httle tincture of iochne. The ai)paratus 
is filled with the saline solution and all air-bubbles are 




Fig. 63. — Hypodermoclysis. 



eliminated. The needle is introduced well under the skin 
into the subcutaneous cellular tissue. The compression upon 
the rubber tubing is released. The funnel is elevated and 



2>72 



SPECIAL TOPICS. 



the fluid is perniitted to flow gently by gravity. A tumor 
immediately appears and increases in size according to the 
amount of fluid injected (Fig. 63). The tumor is gently 
massaged in order to facilitate the distribution of the solu- 
tion under the skin. Should the flow appear tO' be in- 
hibited the needle may be pushed in to its full length and 
pointed in different directions from time to time. When 
suflicient fluid has entered (from 2 to 6 ounces) the needle 
is withdrawn and the puncture sealed with collodion and 




Fig. 64, — Necrosis and ulceration from the subcutaneous injection 
of carbonate of soda and sodium chlorid solution, Slough due to 
the alkali. 



a bandage applied. Within a brief space of time, from one- 
half to one hour, the fluid will have been absorbed and the 
swelling will have disappeared. The injection of the fluid 
is accompanied by very little pain. The temperature of the 
solution in the funnel should be maintained at about 120° F. 
As the fluid leaves the needle-point the temperature will be 
about normal. Too large a quantity of fluid is not to be 
injected at one site, nor should the same site be selected too 
often. Only in this way may gangrene of the skin and 
ulceration be prevented, especially in delicate infants. 
Should a white area appear upon the swelling the injection 



HYPODERMOCLYSIS. 373 

should immediately cease, as this means that the circulation 
of that particular spot has been cut off and gangrene of the 
skin may result. This phenomenon occurs not infrequently 
as the result of placing the needle betza'ccn the layers of the 
skin instead of under the skin, or, as above indicated, from 
permitting too much fluid to enter. Alkalies, such as the 
bicarbonate of soda or the carbonate of soda, should never 
be employed in the solution, as they invariably produce 
gangrene and ulceration (Fig. 64). Abscesses are a rare 
occurrence. 



INDEX. 



Acacia-water, 149 

Adaptation of cows' milk (see 

also Cows' milk, and Artifi- 
cial feeding), 
alkalies in, 90 
home method of, 'Ki, 95 
hygiene of, 96 
indications of success in, 11, 

100 
methods of, 74 
prescription forms, for use in, 

75, 85 
sodium bicarbonate in, 91 
sodium citrate in, 91 
theory of, 68 
Agar-agar, 256 

Albumin-milk (see Eiweissmilch). 
Albumin-water, 121 
Apparatus for general pediatric 

work, 350 
Artificial feeding, 49 
caloric method of, 51 
cereal decoctions in, 51 
deficiency of food elements 

in, 114 
digestive disturbances in, 104- 

114 
formulas for use in, 77-81 
improper quantities of food 

elements in, 115 
in cases of delicate and sick 

infants, 116 
in infantile atrophy, 170 
methods of, 49 
necessity of individualization 

in, 52' 103 
quantities and intervals of, 

101 



Artificial feeding, table, 102 
while travelling, 104 

Babcock's test, 21 
Barley-water in digestive disturb- 
ance of breast-fed, 34 
in fat disturbance, 112 
in protein intolerance, 107 
preparation, 87 
Beef-broths, 145; jelly, 146; teas, 

144 
Benger's food, composition and 
use of, 135 
in diarrhea, 271 
in infantile atrophy, 178 
in infectious diseases, 367 
in protein intolerance, 109 
in pyloric obstruction, 341, 343 
Bottles (see Adaptation, home 

method). 
Breast (see also Mammary gland), 
abscess, 9 
caked, 8 
Breast-feeding (see also Human 
milk), 
advantages of, 26 
contraindications to, 41 
digestive disturbances in, 27 
during illness, 44 
hygiene of mother, 42 
indication^ for, 2 
metabolic and digestive dis- 
turbances in, 32 
method of, 38 

physician's responsibility' in, 1 
successful, 29 

system and regularity in. 28 
table for, 40 

(375) 



376 



INDEX. 



Breast-feeding, unsuccessful, 29 

vomiting in, 23 
Bronchial asthma in exudative 

diathesis, 305 
Broths, 145, 146 
Bulgarian bacilli, 121 
Buttermilk (Blockley) in diarrhea, 
269 

conserve, 125 

in curd division, 71 

indications for, 124 

in fat intolerance, 112 

in infantile atrophy, 175 

in protein intolerance, 110 

in sugar intolerance, 73, 114 

in vomiting, 238 

prepared, 123 

substituted for milk formula, 71 

Calcium casein, 55 

Calomel in diarrhea, 267, 268 

Caloric feeding, 82 

Cane-sugar, 136 

Carbohydrates (see Sugar, etc.). 

Cascara sagrada in constipation, 

257 
Castor oil in diarrhea, 267, 268 

in digestive disturbances of 
breast-fed, 34 

in fat intolerance, 112 

in protein intolerance, 107 

in sugar intolerance, 114 
Celery, stewed, 148 
Cereal-gruels, in infantile atrophy, 
174 

in milk adaptation, 71 

in rickets, 214 

in vomiting, 241' 

preparation of, 86 
Chvostek's sign, 282 
Codliver oil in rickets, 218 

in spasmophilia, 294 
Colostrum, 13, 14 
Condensed milk in rickets, 187 

composition of, 131 



Constipation, 247 
causes of, 247 

correction of formulas in, 249 
fat in, 250 
fruit- juices in, 251 
in the breast-fed, 248 
in complete pyloric obstruction, 

318 
in incomplete pyloric obstruc- 
tion, 325 
in older children, 252 
in rickets, 194 
massage balls in, 258 
medicinal treatment, 254 
spondylotherapy in, 259 
sugar in, 250 
Convulsions in spasmophilia, 294 
Cornmeal gruel, 147 
Cornstarch, 147 
Cows, breeds of, 54 
care of, 62 

use of chloroform in, 294 
Cows' milk (see also Artificial 
feeding, and Adaptation), 
adulteration and contamina- 
tion, 58 
analysis of, 60 
antibodies in, 73 
bacteria in, 57 
collection and care of, 63 
compared with human milk, 

67 
fat in, 54, 72 
grades of, 65 
idiosyncracy to, 118 
microscopic appearance of, 57 
modification of (see Adapta- 
tion), 
protein in, 55, 70 
salts in, 57 
sugar in, 56, 72 

watering and preservatives, 
detection of, 60 
Cream, 55 
Curd modifiers, 133 



INDEX. 



377 



Decomposition (see Infantile atro- 
phy). 
Dermal phenomenon in exudative 

diathesis, 301 
Dcxtri-Maltose, composition, 136 
in infantile atrophy, 180 
in pyloric obstruction, 343 
in sugar intolerance, 114 
Dextrinized gruels as diluents, 86 
in protein intolerance, 108 
preparation of, 89 
Diarrhea, 260 
causes, 260 
in bottle-fed, 269 
in breast-fed, 264 
in children with teeth. 274 
postoperative, in pyloric ob- 
struction, 340 
symptoms of, 262 
treatment of, 265, 266-268, 269 
Diet at 12 months, 138 
table, 140 
at 18 months, 140 

table, 141 
after second year, 141 
table, 142 
Diluents, 85 
Dyspepsia, 107, 264 

Eczema (see also Exudative dia- 
thesis). 

of the cornea (Czerny), — see 
Phlyctenular conjunctivitis. 

of the face and head, 303 

seborrhoische universale, 302, 
303 

vacciniformis, 304 

vesiculosum, 304 
Eggs, 148 
Eiweissmilch, 126 

in acute infections, 368 

in curd division, 71 

in diarrhea, 269 

in infantile atrophy, 177 

in protein intolerance, 110 



Eiweissmilch in sugar intoler- 
ance, IZ, 114 
in vomiting, 238 
preparation of, 126 
Electrical phenomenon in spasmo- 
philia, 284 
Enemata, 356 

in pyloric obstruction, 344 
in vomiting, 341 
medicinal, 368 
nutrient, 364 
Exudative diathesis, 297 
(See also Eczema.) 
association of spasmophilia 

with, 298 
diagnosis of, 307 
etiology of, 297 
respiratory symptoms in, 305 
skin lesions in, 301, 309 
symptoms, general, 300 
treatment of, 308 

Facial phenomenon in spasmo- 
philia, 282 
Farina, 147 

Fat, deficiency of in rickets, 187 
digestion of, 72 
indigestion in breast-fed, 2>Z 
Fat intolerance, 110 
in rickets, 215 
treatment of, 112 
urine in, 112 
vomiting in, 111, 236 
Feeding (see also Artificial feed- 
ing, and Breast feeding. 
The various problems of 
feeding are considered un- 
der their respective titles), 
by bowel (see Enemata, Nu- 
trient), 
by nose (see Nasal feeding), 
by stomach-tube (see Gavage). 
during intubation, 369 
in acute infectious diseases, 365 



378 



INDEX. 



Feeding in nephritis, 369 
stomach capacity, 234 
Flour ball, 71 

dextrinized or browned, 134 
in infectious diseases, 367 
in protein intolerance, 108 
in pyloric obstruction, 343 
preparation of, 133 
Food maximum (von Pirquet), 
105 
minimum (von Pirquet), 105 
Formulas (see Adaptation), 
determination of percentage 
strength, 81 
Fullers' earth in diarrhea, 271 
in exudative diathesis, 309 

Galactogogues, 37 
Gavage, 363 
Gelatin, 149 
Goats' milk, 52 

Holland rusk, 149 
Holt cream gauge, 21 

milk-secretion estimate, 21 
Human milk, analysis of, 18, 25 
bacteriology of, 17 
chemistry and physics of, 14 
composition of, 17 
failure of secretion of, 30 
fat in, 16, 21 
microscopic appearance of, 

14, 25 
modification of, 35-37 
proteins in, 17 
quantity of, 20 
salts in, 17 
significance of leucocytes in, 

25 
sugar in, 17 
Hypodermoclysis in diarrhea, 272 
indications for, 370 
in infantile atrophy, 182 
in vomiting, 241 
technique, 370 



Imperial granum, 136 
Indigestion (see Fat, Sugar and 

Protein intolerance, and In- 
digestions). 
Infantile atrophy, 150 

author's theory of etiology, 
153 

complications in, 162 

diagnosis of, 164 

etiology and pathology of, 150 

starch injury in, 160 

symptoms of, 156 

treatment of, 169-182 

weight curve in, 161 
Intestinal fermentation and de- 
composition, 260, 261 
Intoxication, 113, 264 

Junket, 148 

Lactic acid milk, 121 
Lactic acid tablets (see Bulgarian 
bacilli). 

in infantile atrophy, 113 
Lactose, digestion of, IZ 

estimation of, 24 

in summer diarrhea, 72 

(See Substitutes for malt 
sugar.) 

tablets, 121 
Larosan, 128 

in acute infections, 368 

in diarrhea, 270 

in exudative diathesis, 309 

in infantile atrophy,- 177 
Lavage in pyloric obstruction, 344 

in vomiting, 241 

solutions for, 352 

technique, 352 
Leiner's disease, 303 
Lime-salts, deficiency of, in rick- 
ets, 188 
Lime-water, 148 
Loeflund's food maltose, 136 
Lutein, Zl 



INDEX. 



379 



Magnesia, milk of, in constipation, 

256 
Maltine in infantile atrophy, 174 
Maltose, digestion of, IZ 
Maltropon, Zl , 44 
Malt soup, 71 

in infantile atrophy, 90 
in protein intolerance, 110 
Loeflund's, 89 
sugar, substitutes for, 136 
Mammary gland (see also Breast), 
anatomy and histology of, 3 
hygiene of, 6 
Marasmus (see Infantile atrophy). 
Mead-Johnson's Dextri-Maltose, 

136 
Mehlnahrschaden, 152, 160, 163 
Milk (see Human milk, Cows' 
milk. Goats' milk), 
boiled, in infantile atrophy, 173 
Mineral oil, 254 
Murphy treatment, 241 

Nasal feeding, 361 
Nipples (see also Adaptation, 
home), 
artificial, in breast feeding, 6 
depressed, 8 

excoriations and fissures of, 6, 7 
treatment during puerperium, 6, 
8 
Nutrose in exudative diathesis, 
309 

Oatmeal-water, 88 
Olive oil in constipation, 255 
Onions, stewed, 148 
Orange-juice, 149 

Pancreatization in infantile atro- 
phy, 175 

Pancreatized milk in protein in- 
tolerance, 108 
in fat intolerance, 113 

Paraf Javal's preparation, 184. 241 



Paraf Javal's preparation in in- 
fantile atrophy, 184 
in pyloric obstruction, 345 
in nervous vomiting, 240 
Pasteurized milk, 91 
Pepper & Meigs, method of milk 

adaptation, 49 
Percentage feeding, 74 

method of milk adaptation, 50 
Peroneus phenomenon in spasmo- 
philia, 284 
Phlyctenular conjunctivitis, 304 
Phosphorus in rickets, 218 

in spasmophilia, 294 
Potato, baked, 147 
Pott's disease, similarity to rickets, 

200 
Protein intolerance, 106 

in exudative diathesis (Fink- 

elstein), 300 
in infantile atrophy, 172 
in rickets, 214 
resume of treatment, 110 
stools in, 106, 107 
treatment of, 107 
vomiting in, 238 
Proteins, deficiency of, in rickets, 
187 
determination of, in milk, 22 
digestion of, 70 
Esbach's tube in determination 

of, 24 
formula for determination of, 

24 
indigestion of, ZZ 
Prune-water, 149 
Pruriginous inflammations, 304 
Pyloric obstruction, 313 
artificial feeding in, 344 
charcoal test for, 323, 331 
complete obstruction, 316 
complications in, 334 
diagnosis of, 331 
differential table, 338 
dilated stomach in, 321, 329 



380 



INDEX. 



Pyloric obstruction, etiology and 

pathology of, 314 
gastric peristalsis in, 320, 329 
palpable pylorus, 322, 330 
sodium citrate in, 91 
surgical treatment (Deaver), 

346 
temperature, 324, 331 
treatment of, 337 

surgical, Z2)7 

non-surgical, 341 
urine in, 324, 331 
weight and strength in, 319, 

327 
X-ray studies of, 323, 330 

Ramogen, 129 
in diarrhea, 271 
in infantile atrophy, 173 

Rectal alimentation, 182 

Rice, 146 

Rice-water, 89 

Rickets, 185 
adolesence, rickets of, 206 
anterior fontanelle in, 198 
blood and urine in, 196, 209 
chest deformities in, 199 
compared with poliomyelitis, 

207 
complications in, 213 
craniotabes in, 192 
detention in, 195, 208 
diagnosis of, 210 
digestive disturbances in, 194 
enlargment of organs in, 194 
etiology of, 187 
feeding in, 214-217 

after first year, 217 
headsweating in, 191 
medicinal treatment of, 218 
muscular weakness in, 195 
nervous symptoms in, 209 
non-medicinal treatment of, 220 
pathology of, 185 
prophylaxis, 214 



Rickets, pseudorachitic palsy, 207 

skeletal changes in, 200 

stools in, 194 

symptoms of, 191 

treatment of anemia in, 220 
Rotch's method of milk adaptation, 
50 

Salts of human milk, 34 
Scurvy, 222 
appearance of mouth in, 226 
blood picture in, 226 
complications, 230 
diagnosis of, 228 
distinguished from rheumatism, 

228 
etiology and pathology of, 222, 

223 
symptoms of, 223 
treatment of, 230 
Skimmed milk, 55, 76, 77 
in diarrhea, 237 
in fat intolerance, 112 
in infantile atrophy, 179 
in vomiting, 271 
Sodium bicarbonate in adaptation 

of cows' milk, 91 
Sodium citrate for bovine curds, 
71 
in adaptation of cows' milk, 

91 
in infantile atrophy, 175 
in protein intolerance, 109, 175 
in pyloric obstruction, 91, 346 
in vomiting, due to curds, 238 
Somatose milk, composition of, 
131 
in diarrhea, 271 
in infantile atrophy, 173 
Soup, burnt flour, 146 
Sour milk, 121 
Southworth's soup, Z7, 44 
Soya bean, 133 

Soxhlet's Nahrzucker (see Dextri- 
Maltose), 138 



INDEX. 



381 



Spasmophilia, 276 

association of rickets with, 280 

carpopedal spasm, 288 

Chvostek's sign, 282 

definition of, 276 

diagnosis of, 291 

eclampsia, 289 

electrical reaction, 284 

estimate of electrical reaction 
in, 277, 286 

etiology of, 276 

excretory symptoms, 289 

gastric lavage in, 295 

irregular forms of, 290 

laryngospasmus, 287 

manifestations of, 277 

predisposing causes of, 279 

symptoms of latent spasmo- 
philia, 281 
of manifest spasmophilia, 281 

treatment of, 292, 294 

Trousseau's phenomenon, 283 
Spinach, 147 

Split proteins, 120 (see Whey). 
Spondylotherapy, 259 
Starch atrophy (see Mehlnahr- 
schaden), 152, 160 

in constipation, 251 
Sterilized milk, 94 
Stomach washing (see Lavage). 
Stools in breast feeding, 29 

in diarrhea, 262, 265 

in exudative diathesis, 306 

in fat indigestion and intoler- 
ance, 33, 111 

in infant atrophy, 158 

in protein indigestion, 33 

in rickets, 194 

in scurvy, 224 

in sugar intolerance and indi- 
gestion, 33, 113 

test for fat in, 111 
Strophulus, 304 

Substitutes for malt-sugar, 136 
Sugar, digestion of, 72 



Sugar, excess of, in rickets, 187 
indigestion of, 33 
intolerance, buttermilk in, 73, 
114 
Dextri-Maltose in, 114 
eiweissmilch in, 73, 114 
in diarrhea, 260, 264 
in rickets, 215 
stools in, 113 
symptoms of, 113 
treatment of, 114 
vomiting in, 237 
Summer diarrhea, sugar as cause 
of, 72 
stools in, 262 
vomiting in, 240 
Syphilis, breast feeding in, 41 

Tetany (see Spasmophilia) in 
rickets, 209 

Toast-water, 148 

Top-milk method of milk adapta- 
tion, 50 

Trousseau's phenomenon, 283 

Urine in pyloric obstruction, 324, 
331 
in rickets, 196 
in fat intolerance, 112 
in sugar intolerance, 113 
in protein intolerance, 107 

Vomiting, causes of, 233, 242 

as symptom of hydrocephalus, 
242 

cyclic, 245, 333 

in abdominal disease, 242 

in breast feeding, 29, 33 

in complete pyloric obstruction, 
316 

in diarrhea, 273 

in fat intolerance. 111, 236 

in incomplete pyloric obstruc- 
tion, 325 

in infancy, 232 



382 



INDEX. 



Vomiting in infantile atrophy, 158 
nervous, 239 
in older children, 242 
in postoperative pyloric obstruc- 
tion, 340 
in protein intolerance, 238 
in pyloric obstruction, 238 
in rickets, 194 
in summer diarrhea, 240 
in sugar intolerance, 237 
Paraf Javal solution in, 240 
sodium citrate in, 238 
treatment of, 241, 243 



Weaning, 47 

Weight disturbance, 110 

Wet-nursing, 45 

Wheat-flour water, 88 

Whey, 55 
in cream mixtures, 120 
in fat intolerance, 112 
in infantile atrophy, 172, 179 
in protein intolerance, 107 
in pyloric obstruction, 341, 342 
in vomiting, 241 
preparation of, 119 
wine, 121 

Zweiback, 149 



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